1336628569 NPI number — KEFALOS PHARMACY INC

Table of content: (NPI 1336628569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336628569 NPI number — KEFALOS PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEFALOS PHARMACY INC
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:
VILLAGE PHARMACY
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:
1336628569
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1227 150TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITESTONE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11357-1747
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
347-732-4772
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1227A 150TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITESTONE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11357-1747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-732-4772
Provider Business Practice Location Address Fax Number:
347-732-4532
Provider Enumeration Date:
08/08/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LYMBERATOS
Authorized Official First Name:
DIMITRIOS
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/ PRESIDENT
Authorized Official Telephone Number:
646-476-1881

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  057429 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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