Provider Demographics
NPI:1275684748
Name:QUEENSBRIDGE PLAZA PHARMACY CORP
Entity Type:Organization
Organization Name:QUEENSBRIDGE PLAZA PHARMACY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RONG TIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:YU
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-707-0705
Mailing Address - Street 1:1037 41ST AVE
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-7346
Mailing Address - Country:US
Mailing Address - Phone:718-707-0705
Mailing Address - Fax:718-707-0706
Practice Address - Street 1:1037 41ST AVE
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-7346
Practice Address - Country:US
Practice Address - Phone:718-707-0705
Practice Address - Fax:718-707-0706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-13
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02863936Medicaid
NY5911220001Medicare NSC