Provider Demographics
NPI:1982113221
Name:GREENE PHARMACY 1 INC
Entity type:Organization
Organization Name:GREENE PHARMACY 1 INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NERIYE
Authorized Official - Middle Name:
Authorized Official - Last Name:KAYKOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-433-9530
Mailing Address - Street 1:6545 99TH STREET
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374
Mailing Address - Country:US
Mailing Address - Phone:718-433-9530
Mailing Address - Fax:718-433-9479
Practice Address - Street 1:6545 99TH ST
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4347
Practice Address - Country:US
Practice Address - Phone:718-433-9530
Practice Address - Fax:718-433-9479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-28
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0358913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPENDINGMedicaid
2173407OtherPK