Healthcare Provider Details

I. General information

NPI: 1609278308
Provider Name (Legal Business Name): 139 CENTER PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2014
Last Update Date: 09/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 CENTRE ST STORE 105
NEW YORK NY
10013-4552
US

IV. Provider business mailing address

139 CENTRE ST STORE 105
NEW YORK NY
10013-4552
US

V. Phone/Fax

Practice location:
  • Phone: 646-838-6388
  • Fax: 718-513-2047
Mailing address:
  • Phone: 646-838-6388
  • Fax: 718-513-2047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number033068
License Number StateNY

VIII. Authorized Official

Name: TRISTAN LIU
Title or Position: CORPORATE OFFICER
Credential:
Phone: 646-801-4876