Provider Demographics
NPI:1063596294
Name:HARRICO KNICKERBOCKER DRUG CORP
Entity type:Organization
Organization Name:HARRICO KNICKERBOCKER DRUG CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHARMACIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAMA
Authorized Official - Middle Name:
Authorized Official - Last Name:NOOR
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-452-5521
Mailing Address - Street 1:214 STANHOPE ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-4202
Mailing Address - Country:US
Mailing Address - Phone:718-452-5521
Mailing Address - Fax:718-773-5568
Practice Address - Street 1:214 STANHOPE ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4202
Practice Address - Country:US
Practice Address - Phone:718-452-5521
Practice Address - Fax:718-452-2368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1952183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01451523Medicaid
NY3317888OtherNABP NUMBER
NY1952OtherPHARMACY REGISTRATION NUM
NY1952OtherPHARMACY REGISTRATION NUM
NY5159240001Medicare ID - Type UnspecifiedMEDICARE NUMBER