MEDICARE: BUENA VISTA PHARMACY

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	3336C0003X	Community/Retail Pharmacy	012457	NY

General Provider Information

NPI Number	:	1629282223
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUENA VISTA PHARMACY

Provider Business Mailing Address
First Line	:	2022 THIRD AVE
Second Line	:
City	:	NEW YORK CITY
State	:	NY
Zip	:	10029-2855
Country	:	US
Telephone Number	:	212-369-4018
Fax Number	:	212-831-8851

Provider Business Practice Location Address
First Line	:	2022 THIRD AVE
Second Line	:
City	:	NEW YORK CITY
State	:	NY
Zip	:	10029-2855
Country	:	US
Telephone Number	:	212-369-4018
Fax Number	:	212-831-8851

Authorized Official
Title or Position	:	SUPERVISING PHARMACIST
Name	:	MR. DAVID C RABENOU
Credential	:	PHARMACIST
Telephone Number	:	212-369-4018

Provider Enumeration Date	:	05/10/2007
Last Update Date	:	08/22/2020

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