Healthcare Provider Details

I. General information

NPI: 1902268162
Provider Name (Legal Business Name): 103 PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 2ND AVE STORE 1
NEW YORK NY
10029-5445
US

IV. Provider business mailing address

2002 2ND AVE STORE 1
NEW YORK NY
10029-5445
US

V. Phone/Fax

Practice location:
  • Phone: 212-410-4410
  • Fax: 212-410-4414
Mailing address:
  • Phone: 212-410-4410
  • Fax: 212-410-4414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number034593
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: NASIR MUGHAL
Title or Position: OWNER
Credential:
Phone: 212-410-4410