Healthcare Provider Details

I. General information

NPI: 1316086952
Provider Name (Legal Business Name): LA ALTAGRACIA PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1544 SAINT NICHOLAS AVE # A
NEW YORK NY
10040-4506
US

IV. Provider business mailing address

1544 SAINT NICHOLAS AVE # A
NEW YORK NY
10040-4506
US

V. Phone/Fax

Practice location:
  • Phone: 212-795-5005
  • Fax: 201-567-6744
Mailing address:
  • Phone: 212-795-5005
  • Fax: 201-567-6744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: NASREEN SHAUKAT RIZVI
Title or Position: SUPERVISING PHARMACIST
Credential:
Phone: 212-795-5004