Provider Demographics
NPI:1437770310
Name:KISSENA RX PHARMACY INC
Entity Type:Organization
Organization Name:KISSENA RX PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:TEOH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-563-1079
Mailing Address - Street 1:4207 KISSENA BLVD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-3297
Mailing Address - Country:US
Mailing Address - Phone:917-563-1079
Mailing Address - Fax:917-563-1023
Practice Address - Street 1:4207 KISSENA BLVD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-3297
Practice Address - Country:US
Practice Address - Phone:917-563-1079
Practice Address - Fax:917-563-1023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-01
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06323317Medicaid
NY038034OtherPHARMACY STATE LICENSE