Provider Demographics
NPI:1275630113
Name:MID CONCOURSE PHARMACY INC
Entity Type:Organization
Organization Name:MID CONCOURSE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHARM
Authorized Official - Prefix:
Authorized Official - First Name:MONIR
Authorized Official - Middle Name:
Authorized Official - Last Name:AHAMED
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-367-4540
Mailing Address - Street 1:2106 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-2800
Mailing Address - Country:US
Mailing Address - Phone:718-367-4540
Mailing Address - Fax:718-563-7369
Practice Address - Street 1:2106 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-2800
Practice Address - Country:US
Practice Address - Phone:718-367-4540
Practice Address - Fax:718-563-7369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0189343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00931113Medicaid
2064442OtherPK
5318490001Medicare NSC