1063560027 NPI number — KING KULLEN PHARMACIES CORP

Table of content: (NPI 1063560027)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063560027 NPI number — KING KULLEN PHARMACIES CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KING KULLEN PHARMACIES CORP
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:
KING KULLEN PHARMACY #18
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:
1063560027
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
KING KULLEN GROCERY CO INC
Provider Second Line Business Mailing Address:
185 CENTRAL AVE DEPT 1030
Provider Business Mailing Address City Name:
BETHPAGE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11714-3929
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-733-7100
Provider Business Mailing Address Fax Number:
516-827-6263

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5507 200 NESCONSET HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT SINAI
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11766-2019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-474-0012
Provider Business Practice Location Address Fax Number:
631-473-8515
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HESSE
Authorized Official First Name:
ALBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY COORDINATOR
Authorized Official Telephone Number:
516-733-7100

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: 020241 , 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: 3394741 . This is a "OTHER ID NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01143457 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3394741 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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