MEDICARE: SURFSIDE CHEMISTS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	015178	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3302976	OTHER	OTHER ID NUMBER-COMMERCIAL NUMBER
3	3302976	OTHER	OTHER ID NUMBER

General Provider Information

NPI Number	:	1033124649
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SURFSIDE CHEMISTS

Provider Business Mailing Address
First Line	:	191 LAGOON DR E
Second Line	:
City	:	LIDO BEACH
State	:	NY
Zip	:	11561-4912
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1079 W BEECH ST
Second Line	:
City	:	EAST ATLANTIC BEACH
State	:	NY
Zip	:	11561-1115
Country	:	US
Telephone Number	:	516-432-4816
Fax Number	:	516-432-4853

Authorized Official
Title or Position	:	PRESIDENT
Name	:	HAROLD FOX
Credential	:
Telephone Number	:	516-432-4816

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	07/20/2007

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Directions to “SURFSIDE CHEMISTS ” Practice Location

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