1871151126 NPI number — NILE RIDGE PHARMA CORP.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871151126 NPI number — NILE RIDGE PHARMA CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NILE RIDGE PHARMA 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:
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:
1871151126
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
02/09/2024
NPI Reactivation Date:
07/02/2024

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6922 4TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11209-1502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-333-5746
Provider Business Mailing Address Fax Number:
718-333-5749

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6922 4TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11209-1502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-219-1827
Provider Business Practice Location Address Fax Number:
347-825-2350
Provider Enumeration Date:
06/02/2019

Additional Information

Authorized Official

Authorized Official Last Name:
MANSOUR
Authorized Official First Name:
YASER
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
718-333-5746

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PENDING , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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