Provider Demographics
NPI:1285748251
Name:18TH AVE PHARMACY CORP
Entity type:Organization
Organization Name:18TH AVE PHARMACY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GRIGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:BEYLIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-331-3600
Mailing Address - Street 1:5411 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-1928
Mailing Address - Country:US
Mailing Address - Phone:718-331-3600
Mailing Address - Fax:718-331-3099
Practice Address - Street 1:5411 18TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-1928
Practice Address - Country:US
Practice Address - Phone:718-331-3600
Practice Address - Fax:718-331-3099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0256293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02376772Medicaid
2058804OtherPK
NY4738100001Medicare NSC