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General NPI Number Information
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NPI Number | 1629347414
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Entity Type | Organization
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Legal Business Name | REVIVAL PHARMACY LLC
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Dates
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Enumeration Date | 12/22/2011
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Last Update Date | 03/28/2017
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Provider Practice Location Address
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Address Line | 5369 KINGS HWY
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City | BROOKLYN
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State | NY
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Zip | 11203-6704
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Country | US
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Telephone | 718-298-2222
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Fax | 718-298-3333
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Provider Business Mailing Address
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Address Line | 5359B KINGS HIGHWAY
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City | BROOKLYN
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State | NY
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Zip | 11203
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Country | US
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Telephone | 718-298-2222
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Fax | 718-298-3333
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Authorized Official
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Title or Position | COO
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Name | MOSHE SOSKIN
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Credential |
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Telephone | 718-298-2222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 28RO00134300
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 030991
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License Number State | NY
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Taxonomy #3
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number | NP000806
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License Number State | PA
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Taxonomy #4
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number | 0003191
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License Number State | CT
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