Provider Demographics
NPI:1215048152
Name:158TH STREET NEIGHBORHOOD PHARMACY, LLC
Entity type:Organization
Organization Name:158TH STREET NEIGHBORHOOD PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMEBER
Authorized Official - Prefix:
Authorized Official - First Name:NOAM
Authorized Official - Middle Name:
Authorized Official - Last Name:AVIDAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-585-6188
Mailing Address - Street 1:3103 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-4688
Mailing Address - Country:US
Mailing Address - Phone:718-585-6188
Mailing Address - Fax:718-585-6653
Practice Address - Street 1:3103 3RD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-4688
Practice Address - Country:US
Practice Address - Phone:718-585-6188
Practice Address - Fax:718-585-6653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026148332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02519551Medicaid