Provider Demographics
NPI:1033124649
Name:SURFSIDE CHEMISTS
Entity Type:Organization
Organization Name:SURFSIDE CHEMISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-432-4816
Mailing Address - Street 1:191 LAGOON DR E
Mailing Address - Street 2:
Mailing Address - City:LIDO BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-4912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1079 W BEECH ST
Practice Address - Street 2:
Practice Address - City:EAST ATLANTIC BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-1115
Practice Address - Country:US
Practice Address - Phone:516-432-4816
Practice Address - Fax:516-432-4853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0151783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00331168Medicaid
3302976OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3302976OtherOTHER ID NUMBER