Provider Demographics
NPI:1316463441
Name:PRESTIGE RX LLC
Entity type:Organization
Organization Name:PRESTIGE RX LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ONWER
Authorized Official - Prefix:
Authorized Official - First Name:SALIM
Authorized Official - Middle Name:
Authorized Official - Last Name:FAOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-517-0370
Mailing Address - Street 1:858 DEKALB AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221
Mailing Address - Country:US
Mailing Address - Phone:646-517-0370
Mailing Address - Fax:646-517-0372
Practice Address - Street 1:858 DEKALB AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-1402
Practice Address - Country:US
Practice Address - Phone:646-517-0370
Practice Address - Fax:646-517-0372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-21
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0358253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05082839Medicaid
2171433OtherPK