MEDICARE: WILSON POULTRY MARKET 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	174200000X	Meals Provider

General Provider Information

NPI Number	:	1306771159
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILSON POULTRY MARKET INC

Provider Business Mailing Address
First Line	:	205 WILSON ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11211-7206
Country	:	US
Telephone Number	:	718-384-1061
Fax Number	:

Provider Business Practice Location Address
First Line	:	205 WILSON ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11211-7206
Country	:	US
Telephone Number	:	718-384-1061
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	PINCUS UNGAR
Credential	:
Telephone Number	:	917-642-1034

Provider Enumeration Date	:	06/15/2026
Last Update Date	:	06/15/2026

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