Healthcare Provider Details

I. General information

NPI: 1194011486
Provider Name (Legal Business Name): COMMUNITY CARE RX INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2011
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 SUNNYSIDE BLVD STE 100
PLAINVIEW NY
11803-1539
US

IV. Provider business mailing address

131 SUNNYSIDE BLVD STE 100
PLAINVIEW NY
11803-1539
US

V. Phone/Fax

Practice location:
  • Phone: 347-561-3806
  • Fax: 347-561-3835
Mailing address:
  • Phone: 347-561-3806
  • Fax: 347-561-3835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number030632
License Number StateNY

VII. Legacy identifiers

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

# 1
Identifier2130890
Identifier TypeOTHER
Identifier State
Identifier IssuerPK
# 2
Identifier03361126
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: DR. HOSSAM MAKSOUD
Title or Position: CEO/OWNER
Credential: PHARM D.
Phone: 347-561-3806