Healthcare Provider Details

I. General information

NPI: 1376657353
Provider Name (Legal Business Name): PRO LIFE APOTHECARY CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 02/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 1ST AVE
NEW YORK NY
10065-6311
US

IV. Provider business mailing address

1235 1ST AVE
NEW YORK NY
10065-6311
US

V. Phone/Fax

Practice location:
  • Phone: 212-628-1110
  • Fax: 212-628-1117
Mailing address:
  • Phone: 212-628-1110
  • Fax: 212-628-1117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
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 Number027558
License Number StateNY

VIII. Authorized Official

Name: DAVID RESTEPO
Title or Position: SECRETARY
Credential: RPH
Phone: 212-628-1110