Provider Demographics
NPI:1962773051
Name:YMD PHARMACY, INC.
Entity type:Organization
Organization Name:YMD PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER - OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MO
Authorized Official - Middle Name:A
Authorized Official - Last Name:DALIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-221-6814
Mailing Address - Street 1:519 UTICA AVE
Mailing Address - Street 2:STORE # 3
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-1916
Mailing Address - Country:US
Mailing Address - Phone:718-221-6814
Mailing Address - Fax:718-221-6815
Practice Address - Street 1:519 UTICA AVE
Practice Address - Street 2:STORE # 3
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-1916
Practice Address - Country:US
Practice Address - Phone:718-221-6814
Practice Address - Fax:718-221-6815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-20
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0310623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5804174OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NY03432611Medicaid
NY1962773051OtherNPI
5804174OtherNCPDP PROVIDER IDENTIFICATION NUMBER