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General NPI Number Information
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NPI Number | 1649936980
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Entity Type | Organization
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Legal Business Name | LIC PHARMACY CORP
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Dates
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Enumeration Date | 11/10/2021
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Last Update Date | 11/10/2021
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Provider Practice Location Address
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Address Line | 4035 21ST ST STE 4C
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City | LONG ISLAND CITY
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State | NY
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Zip | 11101-6140
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Country | US
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Telephone | 347-242-2981
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Fax | 347-242-2619
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Provider Business Mailing Address
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Address Line | 4035 21ST ST STE 4C
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City | LONG ISLAND CITY
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State | NY
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Zip | 11101-6140
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Country | US
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Telephone | 347-242-2981
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Fax | 347-242-2619
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. RONG TIAN YU
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Credential | RPH
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Telephone | 347-242-2981
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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 |
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License Number State |
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