Provider Demographics
NPI:1073676821
Name:82 COLUMBUS CORP
Entity Type:Organization
Organization Name:82 COLUMBUS CORP
Other - Org Name:PARK WEST PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:212-721-3883
Mailing Address - Street 1:461 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-5107
Mailing Address - Country:US
Mailing Address - Phone:212-721-3883
Mailing Address - Fax:212-721-5660
Practice Address - Street 1:461 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-5107
Practice Address - Country:US
Practice Address - Phone:212-721-3883
Practice Address - Fax:212-721-5660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY202923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3395111OtherNCPDP #