Provider Demographics
NPI:1376814954
Name:GOLDEN PHOENIX ENTERPRISE CORP
Entity Type:Organization
Organization Name:GOLDEN PHOENIX ENTERPRISE CORP
Other - Org Name:AZE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:YEUNG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-576-3476
Mailing Address - Street 1:4519 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-1495
Mailing Address - Country:US
Mailing Address - Phone:718-576-3476
Mailing Address - Fax:718-576-3459
Practice Address - Street 1:4519 7TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-1495
Practice Address - Country:US
Practice Address - Phone:718-576-3476
Practice Address - Fax:718-576-3459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-13
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6698840001Medicare NSC