=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841623360
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE MEDICINE CHEST LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2013
-----------------------------------------------------
Last Update Date | 09/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4407 15TH AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11219-1604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-633-4246
-----------------------------------------------------
Fax | 718-871-4246
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4407 15TH AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11219-1604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-633-4246
-----------------------------------------------------
Fax | 718-871-4246
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. EFRAIM S HALBERSTAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 917-755-3698
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 031892
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------