Provider Demographics
NPI:1467114934
Name:EP 2020 STORE NO 1 LLC
Entity Type:Organization
Organization Name:EP 2020 STORE NO 1 LLC
Other - Org Name:ECOGREEN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ABOUBACAR
Authorized Official - Middle Name:
Authorized Official - Last Name:SYLLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-559-1280
Mailing Address - Street 1:256 W 116TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-3570
Mailing Address - Country:US
Mailing Address - Phone:646-559-1280
Mailing Address - Fax:646-524-5867
Practice Address - Street 1:256 W 116TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-3570
Practice Address - Country:US
Practice Address - Phone:646-559-1280
Practice Address - Fax:646-524-5867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-12
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy