Provider Demographics
NPI:1194861104
Name:139 PHARMACY, INC.
Entity Type:Organization
Organization Name:139 PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RPH
Authorized Official - Prefix:MR
Authorized Official - First Name:VINAY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-283-6623
Mailing Address - Street 1:3411 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-7407
Mailing Address - Country:US
Mailing Address - Phone:212-283-5764
Mailing Address - Fax:
Practice Address - Street 1:3411 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-7407
Practice Address - Country:US
Practice Address - Phone:212-283-5764
Practice Address - Fax:212-283-5764
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:139 PHARMACY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-29
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015978183500000X
333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3337373OtherNABP
NY01423894Medicaid
NY01423894Medicaid