1790975936 NPI number — MLTK LLC

Table of content: (NPI 1790975936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790975936 NPI number — MLTK LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MLTK LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SHOPRITE PHARMACY OF HYLAN BLVD
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790975936
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 15169
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07192-5169
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-979-0718
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2424 HYLAN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATEN ISLAND
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10306-3117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-979-0718
Provider Business Practice Location Address Fax Number:
718-979-5462
Provider Enumeration Date:
07/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FIGUEROA RIVERA
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
THIRD PARTY ADMINISTRATOR
Authorized Official Telephone Number:
732-521-8439

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 028450 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2069367 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2909479 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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