Provider Demographics
NPI:1306960810
Name:MEDI SPACE DRUGS
Entity type:Organization
Organization Name:MEDI SPACE DRUGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:TENG
Authorized Official - Suffix:I
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:718-961-3373
Mailing Address - Street 1:4139 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-3132
Mailing Address - Country:US
Mailing Address - Phone:718-961-3373
Mailing Address - Fax:718-961-3311
Practice Address - Street 1:4139 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-3132
Practice Address - Country:US
Practice Address - Phone:718-961-3373
Practice Address - Fax:718-961-3311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0250563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3399044OtherNABP/NCPDP
NY02161411Medicaid
NY02161411Medicaid