Provider Demographics
NPI:1003964578
Name:SHAN PHARMACY INC
Entity Type:Organization
Organization Name:SHAN PHARMACY INC
Other - Org Name:SUMNER AVE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUKMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PERSAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-455-7100
Mailing Address - Street 1:103 SUMNER AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-6940
Mailing Address - Country:US
Mailing Address - Phone:718-455-7100
Mailing Address - Fax:718-789-8581
Practice Address - Street 1:103 SUMNER AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-6940
Practice Address - Country:US
Practice Address - Phone:718-455-7100
Practice Address - Fax:718-789-8581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0231893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01706216Medicaid
3397797OtherNCPDP PROVIDER IDENTIFICATION NUMBER