Provider Demographics
NPI:1215311204
Name:FILL HERE LLC
Entity type:Organization
Organization Name:FILL HERE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:LASALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-968-8600
Mailing Address - Street 1:2116 ROCKAWAY PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-5802
Mailing Address - Country:US
Mailing Address - Phone:718-968-8600
Mailing Address - Fax:718-968-8686
Practice Address - Street 1:2116 ROCKAWAY PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-5802
Practice Address - Country:US
Practice Address - Phone:718-968-8600
Practice Address - Fax:718-968-8686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-20
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0335693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7468240001Medicare NSC