Provider Demographics
NPI:1992057939
Name:79TH STREET PHARMACY, INC.
Entity type:Organization
Organization Name:79TH STREET PHARMACY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:USMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TANVIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-370-5978
Mailing Address - Street 1:215 W 79TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-6242
Mailing Address - Country:US
Mailing Address - Phone:646-370-5978
Mailing Address - Fax:646-398-7680
Practice Address - Street 1:215 W 79TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-6242
Practice Address - Country:US
Practice Address - Phone:646-370-5978
Practice Address - Fax:646-398-7680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-14
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0314053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2138136OtherPK