Provider Demographics
NPI:1184635724
Name:CORAL PHARMACY INC
Entity Type:Organization
Organization Name:CORAL PHARMACY INC
Other - Org Name:CORAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:
Authorized Official - Last Name:LICCIARDELLO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:212-795-3894
Mailing Address - Street 1:4126 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-3703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4126 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-3703
Practice Address - Country:US
Practice Address - Phone:212-795-3894
Practice Address - Fax:212-795-3894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027845333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3375929OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY02757880Medicaid
3375929OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY5690320001Medicare NSC