=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790706760
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALTHEALTH PARK SLOPE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2006
-----------------------------------------------------
Last Update Date | 10/04/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1702 8TH AVE STE B
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11215-6104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-788-2898
-----------------------------------------------------
Fax | 718-788-2703
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1702 8TH AVE STE B
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11215-6104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MGING MEMBER
-----------------------------------------------------
Name | NELSON PANG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-788-2898
-----------------------------------------------------
=====================================================
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 | 027602
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------