=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679614697
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHIA PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2007
-----------------------------------------------------
Last Update Date | 03/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31 12 BROADWAY
-----------------------------------------------------
City | LONG ISLAND CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11106-2649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-728-1212
-----------------------------------------------------
Fax | 718-274-6942
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31 12 BROADWAY
-----------------------------------------------------
City | LONG ISLAND CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11106-2649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERVISING PHARMACIST
-----------------------------------------------------
Name | SYED NAQUI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-728-1212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number | 015882
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------