Provider Demographics
NPI:1194864793
Name:MEDINA PHARMACY INC
Entity Type:Organization
Organization Name:MEDINA PHARMACY INC
Other - Org Name:MEDINA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AURORA
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-439-3500
Mailing Address - Street 1:5721 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-3876
Mailing Address - Country:US
Mailing Address - Phone:718-439-3500
Mailing Address - Fax:718-439-5207
Practice Address - Street 1:5721 5TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-3876
Practice Address - Country:US
Practice Address - Phone:718-439-3500
Practice Address - Fax:718-439-5207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0184863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2145101OtherPK
NY5388460001Medicare NSC