=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447345764
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAR ROCKAWAY PHARMACY CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2119 MOTT AVE
-----------------------------------------------------
City | FAR ROCKAWAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11691-3215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-327-2511
-----------------------------------------------------
Fax | 718-327-5887
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2119 MOTT AVE
-----------------------------------------------------
City | FAR ROCKAWAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11691-3215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-327-2511
-----------------------------------------------------
Fax | 718-327-5887
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. PRAVINKUMAR PATEL
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 718-327-2511
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 018895
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------