1043604010 NPI number — EYE OF HORUS PHARMACEUTICAL SERVICES,LLC

Table of content: (NPI 1043604010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043604010 NPI number — EYE OF HORUS PHARMACEUTICAL SERVICES,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE OF HORUS PHARMACEUTICAL SERVICES,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:
Provider Other Organization Name Type Code:
6
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:
1043604010
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:
15 PALOMBA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06082-3888
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-745-0183
Provider Business Mailing Address Fax Number:
860-741-6503

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 PALOMBA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06082-3888
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-745-0183
Provider Business Practice Location Address Fax Number:
860-741-6503
Provider Enumeration Date:
03/26/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MOUSTAFA
Authorized Official First Name:
ASHRAF
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
818-519-6255

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; 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: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PCY0001177 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 008061223 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2152674 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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