Provider Demographics
NPI:1235209313
Name:679 STANLEY AVENUE PHARMACY INC
Entity Type:Organization
Organization Name:679 STANLEY AVENUE PHARMACY INC
Other - Org Name:MARBEN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOOKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-991-6700
Mailing Address - Street 1:PO BOX 120360
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-0360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:679 STANLEY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-7905
Practice Address - Country:US
Practice Address - Phone:718-649-0200
Practice Address - Fax:718-649-0876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027216333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02619809Medicaid
3318929OtherOTHER ID NUMBER-COMMERCIAL NUMBER
5460250001Medicare ID - Type Unspecified