Provider Demographics
NPI:1003359175
Name:CONEY ISLAND CHEMIST INC
Entity Type:Organization
Organization Name:CONEY ISLAND CHEMIST INC
Other - Org Name:CONEY ISLAND CHEMIST INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, AO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKAYEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-587-7200
Mailing Address - Street 1:2384 CONEY ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-5002
Mailing Address - Country:US
Mailing Address - Phone:347-587-7200
Mailing Address - Fax:347-587-7201
Practice Address - Street 1:2384 CONEY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-5002
Practice Address - Country:US
Practice Address - Phone:347-587-7200
Practice Address - Fax:347-587-7201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-22
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0351773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2167558OtherPK
NY04726330Medicaid