Provider Demographics
NPI:1396750907
Name:LYDIG AVENUE PHARMACY CORP
Entity type:Organization
Organization Name:LYDIG AVENUE PHARMACY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MUHAMMAD
Authorized Official - Middle Name:ABID
Authorized Official - Last Name:JAVAID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-678-8700
Mailing Address - Street 1:742 LYDIG AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-2104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:742 LYDIG AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-2104
Practice Address - Country:US
Practice Address - Phone:718-678-8700
Practice Address - Fax:718-678-8777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
NY026027333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3332688OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY02397304Medicaid
3332688OtherOTHER ID NUMBER-COMMERCIAL NUMBER