MEDICARE: CONCORD PHARMACY LLC

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
2	333600000X	Pharmacy	034768	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2162428	OTHER		PK

General Provider Information

NPI Number	:	1710433925
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONCORD PHARMACY LLC

Provider Business Mailing Address
First Line	:	301 E KINGSBRIDGE RD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10458-4443
Country	:	US
Telephone Number	:	929-329-0421
Fax Number	:	347-542-3034

Provider Business Practice Location Address
First Line	:	301 E KINGSBRIDGE RD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10458-4443
Country	:	US
Telephone Number	:	929-329-0421
Fax Number	:	347-542-3034

Authorized Official
Title or Position	:	PHARMACY MANAGER
Name	:	MR. LI H HOM
Credential	:
Telephone Number	:	929-329-0421

Provider Enumeration Date	:	08/28/2016
Last Update Date	:	11/22/2017

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Directions to “CONCORD PHARMACY LLC ” Practice Location

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