Provider Demographics
NPI:1427185057
Name:MONTEFIORE MEDICAL CENTER
Entity Type:Organization
Organization Name:MONTEFIORE MEDICAL CENTER
Other - Org Name:MONTEFIORE COMMUNITY PHARMACY @ MOSES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:W
Authorized Official - Last Name:TUCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-920-5194
Mailing Address - Street 1:111 EAST 210 STREET
Mailing Address - Street 2:FCC BUILDING GROUND FLOOR
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2401
Mailing Address - Country:US
Mailing Address - Phone:718-920-7869
Mailing Address - Fax:718-654-7690
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:FCC BUILDING GROUND FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-920-7869
Practice Address - Fax:718-654-7690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0246083336C0002X, 3336C0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02009598Medicaid
NY024608OtherSTATE LICENSE NUMBER
NY3310810OtherNABP NUMBER