=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134635444
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QK PHARMACY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2017
-----------------------------------------------------
Last Update Date | 12/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13617 39TH AVE STE 1B
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354-5504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-762-3777
-----------------------------------------------------
Fax | 877-757-4276
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13617 39TH AVE STE 1B
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354-5504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-762-3777
-----------------------------------------------------
Fax | 877-757-4276
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. PENG GUO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-762-3777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------