Provider Demographics
NPI:1962543215
Name:DRUG STORE INCORPORATED
Entity type:Organization
Organization Name:DRUG STORE INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST CO OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:AVICOLLI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-982-9438
Mailing Address - Street 1:2204 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6624
Mailing Address - Country:US
Mailing Address - Phone:718-982-9438
Mailing Address - Fax:718-698-8978
Practice Address - Street 1:2204 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6624
Practice Address - Country:US
Practice Address - Phone:718-982-9438
Practice Address - Fax:718-698-8978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0247213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy