MEDICARE: PHARMAKON PHARMACY INC

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	022765	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2058487	OTHER		PK

General Provider Information

NPI Number	:	1104923036
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHARMAKON PHARMACY INC

Provider Business Mailing Address
First Line	:	1914 AVENUE M
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-6361
Country	:	US
Telephone Number	:	718-375-2400
Fax Number	:	718-375-3805

Provider Business Practice Location Address
First Line	:	1914 AVENUE M
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-6202
Country	:	US
Telephone Number	:	718-375-2400
Fax Number	:	718-375-3805

Authorized Official
Title or Position	:	PRES.
Name	:	EDWARD GLAZAROV
Credential	:	RPH
Telephone Number	:	718-375-2400

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	10/26/2023

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