Provider Demographics
NPI:1417301706
Name:NUEVA LUZ PHARMACY INC
Entity Type:Organization
Organization Name:NUEVA LUZ PHARMACY INC
Other - Org Name:NUEVA LUZ PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:RESTREPO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-406-9040
Mailing Address - Street 1:8009 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-6719
Mailing Address - Country:US
Mailing Address - Phone:718-406-9040
Mailing Address - Fax:718-255-6129
Practice Address - Street 1:8009 37TH AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-6719
Practice Address - Country:US
Practice Address - Phone:718-406-9040
Practice Address - Fax:718-255-6129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-22
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0347673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160852OtherPK