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General NPI Number Information
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NPI Number | 1558725853
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Entity Type | Organization
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Legal Business Name | BAYSIDE RX LLC
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Dates
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Enumeration Date | 04/12/2016
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Last Update Date | 04/12/2016
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Provider Practice Location Address
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Address Line | 21411 41ST AVE
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City | BAYSIDE
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State | NY
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Zip | 11361-2133
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Country | US
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Telephone | 347-749-8544
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Fax | 718-522-2388
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Provider Business Mailing Address
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Address Line | 21411 41ST AVE
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City | BAYSIDE
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State | NY
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Zip | 11361-2133
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Country | US
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Telephone | 347-749-8544
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Fax | 718-522-2388
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Authorized Official
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Title or Position | PRESIDENT
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Name | MISS JACLYN PRISCO
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Credential | N/A
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Telephone | 347-749-8544
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336M0003X
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Taxonomy Name | Managed Care Organization Pharmacy
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License Number |
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License Number State | NY
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