Provider Demographics
NPI:1467566430
Name:KINGS BAY PHARMACY
Entity Type:Organization
Organization Name:KINGS BAY PHARMACY
Other - Org Name:SUPER VALUE DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BESLKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-998-6200
Mailing Address - Street 1:2927 AVENUE S
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-3231
Mailing Address - Country:US
Mailing Address - Phone:718-998-6200
Mailing Address - Fax:718-998-6840
Practice Address - Street 1:2927 AVENUE S
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-3231
Practice Address - Country:US
Practice Address - Phone:718-998-6200
Practice Address - Fax:718-998-6840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0247073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3314058OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NY02060066Medicaid
NY02060066Medicaid