=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245580992
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 41 AVENUE PHARMACY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2012
-----------------------------------------------------
Last Update Date | 02/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13633 37TH AVE UNIT 1A
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354-4110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-353-8600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 136-33 37TH AVENUE UNIT #1
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354-5874
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-353-8600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. TRISTAN LIU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 646-504-7321
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 031475
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------