Provider Demographics
NPI:1043604010
Name:EYE OF HORUS PHARMACEUTICAL SERVICES,LLC
Entity Type:Organization
Organization Name:EYE OF HORUS PHARMACEUTICAL SERVICES,LLC
Other - Org Name:ABLE CARE PHARMACY AND MEDICAL SUPPLIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ASHRAF
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUSTAFA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:818-519-6255
Mailing Address - Street 1:15 PALOMBA DR
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-3888
Mailing Address - Country:US
Mailing Address - Phone:860-745-0183
Mailing Address - Fax:860-741-6503
Practice Address - Street 1:15 PALOMBA DR
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3888
Practice Address - Country:US
Practice Address - Phone:860-745-0183
Practice Address - Fax:860-741-6503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-26
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
CTPCY00011773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008061223Medicaid
2152674OtherPK