Provider Demographics
NPI:1003108663
Name:MEDI-SPACE PHARMA INC
Entity Type:Organization
Organization Name:MEDI-SPACE PHARMA INC
Other - Org Name:MEDI-SPACE DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HILTON
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-961-3373
Mailing Address - Street 1:4139 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-3132
Mailing Address - Country:US
Mailing Address - Phone:718-961-3373
Mailing Address - Fax:718-961-3311
Practice Address - Street 1:4139 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-3132
Practice Address - Country:US
Practice Address - Phone:718-961-3373
Practice Address - Fax:718-961-3311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-13
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030843333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1003108663Medicaid
5803918OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NY3338492Medicaid
5803918OtherNCPDP PROVIDER IDENTIFICATION NUMBER