Healthcare Provider Details

I. General information

NPI: 1376691329
Provider Name (Legal Business Name): KING KULLEN PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 02/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

499 SUNRISE HWY STE 64
PATCHOGUE NY
11772-2290
US

IV. Provider business mailing address

KING KULLEN GROCERY CO INC 185 CENTRAL AVE DEPT 1030
BETHPAGE NY
11714-3929
US

V. Phone/Fax

Practice location:
  • Phone: 631-289-0376
  • Fax: 631-447-8890
Mailing address:
  • Phone: 516-733-7100
  • Fax: 516-827-6263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number021207
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01343571
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer
# 2
Identifier3320215
Identifier TypeOTHER
Identifier State
Identifier IssuerOTHER ID NUMBER
# 3
Identifier3320215
Identifier TypeOTHER
Identifier State
Identifier IssuerOTHER ID NUMBER-COMMERCIAL NUMBER

VIII. Authorized Official

Name: ALBERT HESSE
Title or Position: PHARMACY COORDINATOR
Credential: RPH
Phone: 516-733-7100