Healthcare Provider Details

I. General information

NPI: 1427031475
Provider Name (Legal Business Name): 66 NAGLE AVENUE CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 04/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 NAGLE AVE
NEW YORK NY
10040-1406
US

IV. Provider business mailing address

66 NAGLE AVE
NEW YORK NY
10040-1406
US

V. Phone/Fax

Practice location:
  • Phone: 212-304-3949
  • Fax: 212-304-4339
Mailing address:
  • Phone: 212-304-3949
  • Fax: 212-304-4339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number022529
License Number StateNY

VIII. Authorized Official

Name: ROBERT NEWMAN
Title or Position: PHARMACIST/VP
Credential:
Phone: 212-304-3949