=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033825005
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEACON PHARMACY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2023
-----------------------------------------------------
Last Update Date | 01/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4008 JERUSALEM AVE
-----------------------------------------------------
City | SEAFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11783-1612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-590-7388
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 BLUEBIRD DR
-----------------------------------------------------
City | SYOSSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11791-4903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-641-1523
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SAIRA AHMED
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 516-641-1523
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------