Healthcare Provider Details

I. General information

NPI: 1790217891
Provider Name (Legal Business Name): FUSION APOTHECARY LCC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 03/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1158 2ND AVE
NEW YORK NY
10065-8504
US

IV. Provider business mailing address

1158 2ND AVE
NEW YORK NY
10065-8504
US

V. Phone/Fax

Practice location:
  • Phone: 191-747-2789
  • Fax:
Mailing address:
  • Phone: 191-747-2789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number034764
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number034764
License Number StateNY

VIII. Authorized Official

Name: MR. ALEX SAPIR
Title or Position: PHARMACY MANAGER
Credential: RPH
Phone: 19174727895