Provider Demographics
NPI:1225154339
Name:LYDIG AVENUE PHARMACY CORP.
Entity Type:Organization
Organization Name:LYDIG AVENUE PHARMACY CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYUDMILA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHALOM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-678-8700
Mailing Address - Street 1:742 LYDIG AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-2104
Mailing Address - Country:US
Mailing Address - Phone:718-678-8700
Mailing Address - Fax:718-678-8777
Practice Address - Street 1:742 LYDIG AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-2104
Practice Address - Country:US
Practice Address - Phone:718-678-8700
Practice Address - Fax:718-678-8777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02397304Medicaid
NY02397304Medicaid