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General NPI Number Information
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NPI Number | 1366154288
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Entity Type | Organization
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Legal Business Name | PEACH TREE PHARMACY INC
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Dates
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Enumeration Date | 12/22/2022
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Last Update Date | 12/22/2022
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Provider Practice Location Address
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Address Line | 2492 ADAM CLAYTON POWELL JR BLVD
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City | NEW YORK
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State | NY
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Zip | 10030-1340
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Country | US
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Telephone | 646-755-8262
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Fax | 646-755-8263
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Provider Business Mailing Address
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Address Line | 2492 ADAM CLAYTON POWELL JR BLVD
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City | NEW YORK
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State | NY
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Zip | 10030-1340
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Country | US
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Telephone | 646-755-8262
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Fax | 646-755-8263
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Authorized Official
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Title or Position | OWNER
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Name | ALEXANDER LISYANSKY
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Credential |
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Telephone | 908-320-1027
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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