Provider Demographics
NPI:1417448945
Name:1400 ST NICHOLAS LLC
Entity Type:Organization
Organization Name:1400 ST NICHOLAS LLC
Other - Org Name:SAFE HEART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAVALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-568-5454
Mailing Address - Street 1:1400 SAINT NICHOLAS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-4027
Mailing Address - Country:US
Mailing Address - Phone:212-568-5454
Mailing Address - Fax:212-568-5340
Practice Address - Street 1:1400 SAINT NICHOLAS AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-4027
Practice Address - Country:US
Practice Address - Phone:212-568-5454
Practice Address - Fax:212-568-5340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-21
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177835OtherPK