Provider Demographics
NPI:1073972659
Name:HAYATT PHARMACY CORP
Entity Type:Organization
Organization Name:HAYATT PHARMACY CORP
Other - Org Name:HAYATT PHARMACY CORP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOUDEH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:347-662-6119
Mailing Address - Street 1:6920 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-1507
Mailing Address - Country:US
Mailing Address - Phone:347-662-6119
Mailing Address - Fax:347-517-4308
Practice Address - Street 1:6920 5TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-1507
Practice Address - Country:US
Practice Address - Phone:347-662-6119
Practice Address - Fax:347-517-4308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-11
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
NY0343423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158315OtherPK
2158315OtherPK