Provider Demographics
NPI:1407626070
Name:108 PHARMACY INC
Entity Type:Organization
Organization Name:108 PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BADALOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-752-0490
Mailing Address - Street 1:4502 108TH ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-2917
Mailing Address - Country:US
Mailing Address - Phone:718-847-1982
Mailing Address - Fax:718-228-4985
Practice Address - Street 1:4502 108TH ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-2917
Practice Address - Country:US
Practice Address - Phone:718-847-1982
Practice Address - Fax:718-228-4985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy