Healthcare Provider Details

I. General information

NPI: 1467488171
Provider Name (Legal Business Name): PANTAK INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53-82 65TH PLACE
MASPETH NY
11378-1654
US

IV. Provider business mailing address

53-82 65TH PLACE
MASPETH NY
11378-1654
US

V. Phone/Fax

Practice location:
  • Phone: 718-429-4646
  • Fax: 718-335-4421
Mailing address:
  • Phone: 718-429-4646
  • Fax: 718-335-4421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number022664
License Number StateNY

VIII. Authorized Official

Name: MR. MARK FOTAKIS
Title or Position: PRESIDENT
Credential: RPH
Phone: 718-429-4646