Provider Demographics
NPI:1376946640
Name:FONTAK INC
Entity Type:Organization
Organization Name:FONTAK INC
Other - Org Name:RYAN MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:516-459-5009
Mailing Address - Street 1:2000 N VILLAGE AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-1078
Mailing Address - Country:US
Mailing Address - Phone:516-362-2422
Mailing Address - Fax:516-442-6111
Practice Address - Street 1:2000 N VILLAGE AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-1078
Practice Address - Country:US
Practice Address - Phone:516-362-2422
Practice Address - Fax:516-442-6111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7335660001OtherMEDICARE PTAN
NY7335660001Medicare NSC