=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821157140
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 61 WEST KINGSBRIDGE PEOPLE'S DRUG
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 61 W KINGSBRIDGE RD
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10468-7512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-543-2813
-----------------------------------------------------
Fax | 718-543-2888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 61 W KINGSBRIDGE RD
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10468-7512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-543-2813
-----------------------------------------------------
Fax | 718-543-2888
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GUS GARCIA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-543-2813
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 019406
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------