Provider Demographics
NPI:1053698951
Name:WEST 142ND STREET PHARMACY CORP
Entity type:Organization
Organization Name:WEST 142ND STREET PHARMACY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYUBA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALAKOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-704-5601
Mailing Address - Street 1:3471 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-5628
Mailing Address - Country:US
Mailing Address - Phone:212-234-8400
Mailing Address - Fax:212-234-7700
Practice Address - Street 1:3471 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-5628
Practice Address - Country:US
Practice Address - Phone:212-234-8400
Practice Address - Fax:212-234-7700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-07
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0309343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2132630OtherPK
6624820001Medicare NSC