Provider Demographics
NPI:1154535110
Name:DALIZA PHARMACY INC.
Entity type:Organization
Organization Name:DALIZA PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:BA BUSINESS
Authorized Official - Phone:212-281-9410
Mailing Address - Street 1:3481 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-5612
Mailing Address - Country:US
Mailing Address - Phone:212-281-9410
Mailing Address - Fax:212-281-9282
Practice Address - Street 1:3481 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-5612
Practice Address - Country:US
Practice Address - Phone:212-281-9410
Practice Address - Fax:212-281-9282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0171133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00594087Medicaid