Provider Demographics
NPI:1376533083
Name:ALLERTON PARK PHARMACY INC
Entity Type:Organization
Organization Name:ALLERTON PARK PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:MR
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:
Authorized Official - Last Name:MALIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-881-0555
Mailing Address - Street 1:645 ALLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-7403
Mailing Address - Country:US
Mailing Address - Phone:718-881-0555
Mailing Address - Fax:718-881-8697
Practice Address - Street 1:645 ALLERTON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-7403
Practice Address - Country:US
Practice Address - Phone:718-881-0555
Practice Address - Fax:718-881-8697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018137333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00824924Medicaid
NY00824924Medicaid