Provider Demographics
NPI:1376657353
Name:PRO LIFE APOTHECARY CORP
Entity Type:Organization
Organization Name:PRO LIFE APOTHECARY CORP
Other - Org Name:VITAHEALTH APOTHECARY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:RESTEPO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:212-628-1110
Mailing Address - Street 1:1235 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-6311
Mailing Address - Country:US
Mailing Address - Phone:212-628-1110
Mailing Address - Fax:212-628-1117
Practice Address - Street 1:1235 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6311
Practice Address - Country:US
Practice Address - Phone:212-628-1110
Practice Address - Fax:212-628-1117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
NY0275583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02779573Medicaid
2068111OtherPK
NY02779573Medicaid