Provider Demographics
NPI:1205181609
Name:NEW ISLAND PHARMACY INC
Entity Type:Organization
Organization Name:NEW ISLAND PHARMACY INC
Other - Org Name:NEW ISLAND PHARMACY INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:NIDHIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-392-4800
Mailing Address - Street 1:1912 DEER PARK AVE STE A
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-3332
Mailing Address - Country:US
Mailing Address - Phone:631-392-4800
Mailing Address - Fax:631-392-4801
Practice Address - Street 1:1912 DEER PARK AVE
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-3332
Practice Address - Country:US
Practice Address - Phone:631-392-4800
Practice Address - Fax:631-392-4801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-23
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0314083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6716630001Medicaid
2136722OtherPK