Provider Demographics
NPI:1467488171
Name:PANTAK INC.
Entity Type:Organization
Organization Name:PANTAK INC.
Other - Org Name:HILL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:FOTAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-429-4646
Mailing Address - Street 1:53-82 65TH PLACE
Mailing Address - Street 2:
Mailing Address - City:MASPETH
Mailing Address - State:NY
Mailing Address - Zip Code:11378-1654
Mailing Address - Country:US
Mailing Address - Phone:718-429-4646
Mailing Address - Fax:718-335-4421
Practice Address - Street 1:53-82 65TH PLACE
Practice Address - Street 2:
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-1654
Practice Address - Country:US
Practice Address - Phone:718-429-4646
Practice Address - Fax:718-335-4421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0226643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01569153Medicaid
NY3373874OtherNCPDP #