Provider Demographics
NPI:1063576163
Name:MLK PHARMACY,INC
Entity type:Organization
Organization Name:MLK PHARMACY,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DINESH
Authorized Official - Middle Name:D
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:212-666-6060
Mailing Address - Street 1:568 W 125TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-3407
Mailing Address - Country:US
Mailing Address - Phone:212-666-6060
Mailing Address - Fax:212-663-2072
Practice Address - Street 1:568 W 125TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-3407
Practice Address - Country:US
Practice Address - Phone:212-666-6060
Practice Address - Fax:212-663-2072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020626183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01203070Medicaid
NY3396947OtherNABP#
NYBM2285852OtherDEA REGISTRATION
NY1273990001Medicare ID - Type Unspecified