Provider Demographics
NPI:1235440561
Name:ST LUKES ROOSEVELT HOSPITAL CENTER
Entity Type:Organization
Organization Name:ST LUKES ROOSEVELT HOSPITAL CENTER
Other - Org Name:WEST VILLAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MAISOUN
Authorized Official - Middle Name:
Authorized Official - Last Name:SIOUFI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-636-3600
Mailing Address - Street 1:PO BOX 95000-7570
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-7570
Mailing Address - Country:US
Mailing Address - Phone:212-604-1780
Mailing Address - Fax:212-604-1763
Practice Address - Street 1:275 7TH AVE FL 12
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-6995
Practice Address - Country:US
Practice Address - Phone:212-604-1780
Practice Address - Fax:212-604-1763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-01
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0301983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03247087Medicaid
2127630OtherPK