Provider Demographics
NPI:1972518595
Name:2818 FULTON STREET PHARMACY INC
Entity type:Organization
Organization Name:2818 FULTON STREET PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-991-3519
Mailing Address - Street 1:PO BOX 740054
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10474-0001
Mailing Address - Country:US
Mailing Address - Phone:718-235-6394
Mailing Address - Fax:718-874-3903
Practice Address - Street 1:2818 FULTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-2608
Practice Address - Country:US
Practice Address - Phone:718-235-6394
Practice Address - Fax:718-874-3903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0283923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2059782OtherPK
NY02861181Medicaid
NY02861181Medicaid