Provider Demographics
NPI:1124181854
Name:1699 FANCY PHARMACY INC.
Entity Type:Organization
Organization Name:1699 FANCY PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RADIF
Authorized Official - Middle Name:MUHAMMAD
Authorized Official - Last Name:RASHID
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:212-529-4532
Mailing Address - Street 1:132 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-3008
Mailing Address - Country:US
Mailing Address - Phone:212-529-4532
Mailing Address - Fax:212-529-5217
Practice Address - Street 1:132 ALLEN ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-3008
Practice Address - Country:US
Practice Address - Phone:212-529-4532
Practice Address - Fax:212-529-5217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-17
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0199893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01115113Medicaid
NY5420780001Medicare ID - Type Unspecified