Provider Demographics
NPI:1275907529
Name:KINGS PHARMACY INC
Entity Type:Organization
Organization Name:KINGS PHARMACY INC
Other - Org Name:NEW YORK AVE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BISSAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-856-8048
Mailing Address - Street 1:3424 CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2714
Mailing Address - Country:US
Mailing Address - Phone:718-856-8048
Mailing Address - Fax:718-469-0424
Practice Address - Street 1:3424 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2714
Practice Address - Country:US
Practice Address - Phone:718-856-8048
Practice Address - Fax:718-469-0424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-24
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
NY0342893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04376876Medicaid
2157644OtherPK
NY04376876Medicaid