=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124073978
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAR ROCKAWAY DRUGS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2006
-----------------------------------------------------
Last Update Date | 01/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17 27 SEAGIRT BLVD
-----------------------------------------------------
City | FAR ROCKAWAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-471-2500
-----------------------------------------------------
Fax | 718-471-0840
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 27 SEAGIRT BLVD
-----------------------------------------------------
City | FAR ROCKAWAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-471-2500
-----------------------------------------------------
Fax | 718-471-0840
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHCY SUPERVISOR
-----------------------------------------------------
Name | STEVEN BLICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-471-2500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 027366
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------