Provider Demographics
NPI:1053356261
Name:PRIME PSI INC
Entity type:Organization
Organization Name:PRIME PSI INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FAZAL
Authorized Official - Middle Name:
Authorized Official - Last Name:RAHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-828-0428
Mailing Address - Street 1:2500 SAINT RAYMONDS AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-3146
Mailing Address - Country:US
Mailing Address - Phone:718-792-0360
Mailing Address - Fax:718-792-0361
Practice Address - Street 1:2500 SAINT RAYMONDS AVE
Practice Address - Street 2:STE 104
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-3146
Practice Address - Country:US
Practice Address - Phone:718-792-0360
Practice Address - Fax:718-792-0361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0277123336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02749351Medicaid
3350410OtherNCPDP PROVIDER IDENTIFICATION NUMBER