Provider Demographics
NPI:1013180884
Name:KING KULLEN PHARMACIES CORP
Entity Type:Organization
Organization Name:KING KULLEN PHARMACIES CORP
Other - Org Name:KING KULLEN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:J
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-733-7147
Mailing Address - Street 1:185 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714
Mailing Address - Country:US
Mailing Address - Phone:516-733-7196
Mailing Address - Fax:516-827-6263
Practice Address - Street 1:1441 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314
Practice Address - Country:US
Practice Address - Phone:718-698-2632
Practice Address - Fax:718-698-1945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0288123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3357678OtherNCPDP
NY02965608Medicaid
3357678OtherOTHER ID NUMBER
NY02965608Medicaid