MEDICARE: AUSTRA LINE PHARMACY 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	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336S0011X	Specialty Pharmacy
4	3336C0003X	Community/Retail Pharmacy	027830	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2068227	OTHER		PK

General Provider Information

NPI Number	:	1821102716
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUSTRA LINE PHARMACY INC.

Provider Business Mailing Address
First Line	:	5916 GLENWOOD RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-1817
Country	:	US
Telephone Number	:	718-531-6000
Fax Number	:	718-531-6004

Provider Business Practice Location Address
First Line	:	5916 GLENWOOD RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-1817
Country	:	US
Telephone Number	:	718-531-6000
Fax Number	:	718-531-6004

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHINEDU AGBASIONWE
Credential	:	RPH
Telephone Number	:	718-531-6000

Provider Enumeration Date	:	08/18/2006
Last Update Date	:	02/20/2017

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