Healthcare Provider Details

I. General information

NPI: 1194861104
Provider Name (Legal Business Name): 139 PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3411 BROADWAY
NEW YORK NY
10031-7407
US

IV. Provider business mailing address

3411 BROADWAY
NEW YORK NY
10031-7407
US

V. Phone/Fax

Practice location:
  • Phone: 212-283-5764
  • Fax: 212-283-5764
Mailing address:
  • Phone: 212-283-5764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number015978
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. VINAY WALTER
Title or Position: RPH
Credential:
Phone: 212-283-6623