Provider Demographics
NPI:1215130992
Name:Y S DRUG STORE, INC
Entity type:Organization
Organization Name:Y S DRUG STORE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAE GON
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-542-9766
Mailing Address - Street 1:13698 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5510
Mailing Address - Country:US
Mailing Address - Phone:718-461-5500
Mailing Address - Fax:718-461-5501
Practice Address - Street 1:13698 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5510
Practice Address - Country:US
Practice Address - Phone:718-461-5500
Practice Address - Fax:718-461-5501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3330898OtherNCPDP
NY00712496Medicaid
4658560001Medicare NSC