Provider Demographics
NPI:1245388206
Name:KING KULLEN PHARMACY
Entity Type:Organization
Organization Name:KING KULLEN PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:HESSE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:516-733-7100
Mailing Address - Street 1:KING KULLEN GROCERY CO INC
Mailing Address - Street 2:185 CENTRAL AVE DEPT 1030
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-3929
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:575 NESCONSET HWY
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-2758
Practice Address - Country:US
Practice Address - Phone:631-366-1062
Practice Address - Fax:631-979-6574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0197663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3391365OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY01077132Medicaid
3391365OtherOTHER ID NUMBER
5182210003Medicare NSC