=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154479111
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KING KULLEN PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2007
-----------------------------------------------------
Last Update Date | 02/24/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 455 PARK AVE
-----------------------------------------------------
City | LINDENHURST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11757-5250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-225-6230
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | KING KULLEN GROCERY CO INC 185 CENTRAL AVE DEPT 1030
-----------------------------------------------------
City | BETHPAGE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11714-3929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-733-7100
-----------------------------------------------------
Fax | 516-827-6263
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY COORDINATOR
-----------------------------------------------------
Name | ALBERT HESSE
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 516-733-7100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 019746
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------