Provider Demographics
NPI:1093732513
Name:86TH STREET COMMUNITY PHARMACY CORP.
Entity Type:Organization
Organization Name:86TH STREET COMMUNITY PHARMACY CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:UGUALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-218-2360
Mailing Address - Street 1:2789 86TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-4433
Mailing Address - Country:US
Mailing Address - Phone:718-266-2137
Mailing Address - Fax:718-266-2142
Practice Address - Street 1:2789 86TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-4433
Practice Address - Country:US
Practice Address - Phone:718-266-2137
Practice Address - Fax:718-266-2142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02389128Medicaid
NY3331991OtherNADP
NY3331991OtherNADP