=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396916961
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEKOS RED HOOK DRUG STORE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2008
-----------------------------------------------------
Last Update Date | 02/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7501 N BROADWAY
-----------------------------------------------------
City | RED HOOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12571-1437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-758-5057
-----------------------------------------------------
Fax | 845-758-3761
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7501 N BROADWAY
-----------------------------------------------------
City | RED HOOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12571-1437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-758-5057
-----------------------------------------------------
Fax | 845-758-3761
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PETER NEKOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 845-758-5057
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 025060
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------