Provider Demographics
NPI:1396861662
Name:OMEGA PHARMACY INC
Entity Type:Organization
Organization Name:OMEGA PHARMACY INC
Other - Org Name:OMEGA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:FUZAYLOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-234-4666
Mailing Address - Street 1:1439 AMSTERDAM AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-7436
Mailing Address - Country:US
Mailing Address - Phone:212-234-4666
Mailing Address - Fax:212-234-8809
Practice Address - Street 1:1439 AMSTERDAM AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-7436
Practice Address - Country:US
Practice Address - Phone:212-234-4666
Practice Address - Fax:212-234-8809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0282203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2126206OtherPK
NY02867527Medicaid
NY02867527Medicaid