Provider Demographics
NPI:1215387931
Name:SKS PHARMACY LLC
Entity Type:Organization
Organization Name:SKS PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAHARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-385-6000
Mailing Address - Street 1:611 LIVONIA AVE.
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-9524
Mailing Address - Country:US
Mailing Address - Phone:718-385-6000
Mailing Address - Fax:
Practice Address - Street 1:611 LIVONIA AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-5308
Practice Address - Country:US
Practice Address - Phone:718-385-6000
Practice Address - Fax:718-385-6000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-14
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0345943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04586063Medicaid
2160598OtherPK
NY04586063Medicaid