Provider Demographics
NPI:1194845016
Name:NUTRIPHARM
Entity Type:Organization
Organization Name:NUTRIPHARM
Other - Org Name:ACTIONCARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:SOHN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:212-633-2288
Mailing Address - Street 1:49A 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-5103
Mailing Address - Country:US
Mailing Address - Phone:212-633-2288
Mailing Address - Fax:212-633-2712
Practice Address - Street 1:49A 8TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10014-5103
Practice Address - Country:US
Practice Address - Phone:212-633-2288
Practice Address - Fax:212-633-2712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0230743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01676897Medicaid
NY01676897Medicaid