Provider Demographics
NPI:1164435756
Name:FSNR SNF LLC
Entity Type:Organization
Organization Name:FSNR SNF LLC
Other - Org Name:FOUR SEASONS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAATAL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-688-8755
Mailing Address - Street 1:1222 EAST 96TH STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236
Mailing Address - Country:US
Mailing Address - Phone:718-688-8755
Mailing Address - Fax:718-688-8774
Practice Address - Street 1:1222 EAST 96TH STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236
Practice Address - Country:US
Practice Address - Phone:718-688-8755
Practice Address - Fax:718-688-8774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1835G0303X, 333600000X, 3336L0003X
NY0274763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336L0003XSuppliersPharmacyLong Term Care PharmacyGroup - Single Specialty
No1835G0303XPharmacy Service ProvidersPharmacistGeriatricGroup - Single Specialty
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02829849Medicaid
2067555OtherPK
NY05632944Medicaid