Provider Demographics
NPI:1477140077
Name:SAN AGUSTIN PHARMACY LLC
Entity Type:Organization
Organization Name:SAN AGUSTIN PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMBIORIX
Authorized Official - Middle Name:AGUSTIN
Authorized Official - Last Name:POLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-568-1020
Mailing Address - Street 1:4157 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-3702
Mailing Address - Country:US
Mailing Address - Phone:212-568-1020
Mailing Address - Fax:212-781-4157
Practice Address - Street 1:4157 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-3702
Practice Address - Country:US
Practice Address - Phone:212-568-1020
Practice Address - Fax:212-781-4157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-29
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy