Provider Demographics
NPI:1962721688
Name:NATES SPECIALTY PHARMACY CORP
Entity type:Organization
Organization Name:NATES SPECIALTY PHARMACY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:NATENZON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-734-4662
Mailing Address - Street 1:516 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-2804
Mailing Address - Country:US
Mailing Address - Phone:718-720-3710
Mailing Address - Fax:718-360-9650
Practice Address - Street 1:2304 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-3840
Practice Address - Country:US
Practice Address - Phone:718-338-0709
Practice Address - Fax:718-338-3880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-20
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
NY0300933336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03250222Medicaid
5800215OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5800215OtherNCPDP PROVIDER IDENTIFICATION NUMBER