MEDICARE: FRESH POND RX 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	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1720557523
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRESH POND RX INC

Provider Business Mailing Address
First Line	:	7104 FRESH POND RD
Second Line	:
City	:	RIDGEWOOD
State	:	NY
Zip	:	11385-5905
Country	:	US
Telephone Number	:	929-295-0033
Fax Number	:	929-295-0408

Provider Business Practice Location Address
First Line	:	7104 FRESH POND RD
Second Line	:
City	:	RIDGEWOOD
State	:	NY
Zip	:	11385-5905
Country	:	US
Telephone Number	:	929-295-0033
Fax Number	:	929-295-0408

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PATRICK STUART OBRIEN
Credential	:
Telephone Number	:	929-295-0033

Provider Enumeration Date	:	11/21/2018
Last Update Date	:	03/04/2019

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