=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699154732
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELMWAY II PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2015
-----------------------------------------------------
Last Update Date | 05/21/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8607 51ST AVE
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11373-3922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-699-1882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8607 51ST AVE
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11373-3922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-699-1882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CORP. OFFICER
-----------------------------------------------------
Name | TRISTAN LIU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-699-1882
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 033562
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------