Provider Demographics
NPI:1275664302
Name:1413 FULTON ST PHARMACY, CORP.
Entity Type:Organization
Organization Name:1413 FULTON ST PHARMACY, CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRES.
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:BERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-638-5088
Mailing Address - Street 1:1413 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-2607
Mailing Address - Country:US
Mailing Address - Phone:718-638-5088
Mailing Address - Fax:516-371-1814
Practice Address - Street 1:1413 FULTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-2607
Practice Address - Country:US
Practice Address - Phone:718-638-5088
Practice Address - Fax:516-371-1814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015396183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00263185Medicaid