Healthcare Provider Details

I. General information

NPI: 1063562551
Provider Name (Legal Business Name): ST LUKES ROOSEVELT HOSPITAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 06/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 W 12TH ST
NEW YORK NY
10011-7762
US

IV. Provider business mailing address

203 W 12TH ST
NEW YORK NY
10011-7762
US

V. Phone/Fax

Practice location:
  • Phone: 212-604-1970
  • Fax: 212-604-1971
Mailing address:
  • Phone: 212-604-1970
  • Fax: 212-604-1971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number030198
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DENISE FAHMIE
Title or Position: PHARMACY DIRECTOR
Credential:
Phone: 212-604-1975