Provider Demographics
NPI:1326171018
Name:PORT CHEMIST INC
Entity Type:Organization
Organization Name:PORT CHEMIST INC
Other - Org Name:PORT CHEMIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ZORAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:POD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-883-3837
Mailing Address - Street 1:4 AND 4A MANORHAVEN BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050
Mailing Address - Country:US
Mailing Address - Phone:516-883-3837
Mailing Address - Fax:516-883-3879
Practice Address - Street 1:4 AND 4A MANORHAVEN BLVD
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050
Practice Address - Country:US
Practice Address - Phone:516-883-3837
Practice Address - Fax:516-883-3879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028352332B00000X, 3336L0003X
333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02492157Medicaid
3308536OtherOTHER ID NUMBER
NY02492157Medicaid