Healthcare Provider Details

I. General information

NPI: 1629282223
Provider Name (Legal Business Name): BUENA VISTA PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2022 THIRD AVE
NEW YORK CITY NY
10029-2855
US

IV. Provider business mailing address

2022 THIRD AVE
NEW YORK CITY NY
10029-2855
US

V. Phone/Fax

Practice location:
  • Phone: 212-369-4018
  • Fax: 212-831-8851
Mailing address:
  • Phone: 212-369-4018
  • Fax: 212-831-8851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number012457
License Number StateNY

VIII. Authorized Official

Name: MR. DAVID C RABENOU
Title or Position: SUPERVISING PHARMACIST
Credential: PHARMACIST
Phone: 212-369-4018