MEDICARE: KINGS BRONX, 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	183500000X	Pharmacist	044114	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3312458	OTHER	NY	NCPDP

General Provider Information

NPI Number	:	1801958731
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINGS BRONX, INC

Provider Business Mailing Address
First Line	:	545 SAINT PAULS PL
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10456-2122
Country	:	US
Telephone Number	:	718-992-6881
Fax Number	:	718-992-0055

Provider Business Practice Location Address
First Line	:	545 SAINT PAULS PL
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10456-2122
Country	:	US
Telephone Number	:	718-992-6881
Fax Number	:	718-992-0055

Authorized Official
Title or Position	:	SUPERVISING PHARMACIST
Name	:	SHAMSUL K BAKAR
Credential	:	R.PH.
Telephone Number	:	718-992-6881

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	11/18/2007

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