Healthcare Provider Details

I. General information

NPI: 1467817734
Provider Name (Legal Business Name): KING KULLEN PHARMACIES CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2015
Last Update Date: 12/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 E SUNRISE HWY
PATCHOGUE NY
11772-2254
US

IV. Provider business mailing address

185 CENTRAL AVE
BETHPAGE NY
11714-3927
US

V. Phone/Fax

Practice location:
  • Phone: 631-758-8292
  • Fax: 631-758-0139
Mailing address:
  • Phone: 516-733-7100
  • Fax: 516-827-6263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: BRIAN C. CULLEN
Title or Position: PRESIDENT
Credential:
Phone: 516-733-7100