Provider Demographics
NPI:1164805164
Name:PROVISTA SERVICES INC
Entity Type:Organization
Organization Name:PROVISTA SERVICES INC
Other - Org Name:FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:SALMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-401-3900
Mailing Address - Street 1:2754 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-4036
Mailing Address - Country:US
Mailing Address - Phone:718-401-3900
Mailing Address - Fax:718-401-3909
Practice Address - Street 1:2754 3RD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-4036
Practice Address - Country:US
Practice Address - Phone:718-401-3900
Practice Address - Fax:718-401-3909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-08
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0337953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2153408OtherPK
2153408OtherPK