Provider Demographics
NPI:1013232578
Name:PREMIUM PHARMACY INC
Entity Type:Organization
Organization Name:PREMIUM PHARMACY INC
Other - Org Name:PREMIUM PHARMACY INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-886-7128
Mailing Address - Street 1:4110A MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-3167
Mailing Address - Country:US
Mailing Address - Phone:718-886-7128
Mailing Address - Fax:718-886-7138
Practice Address - Street 1:4110A MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-3167
Practice Address - Country:US
Practice Address - Phone:718-886-7128
Practice Address - Fax:718-886-7138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-28
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0300593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5800099OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5800099OtherNCPDP PROVIDER IDENTIFICATION NUMBER