Provider Demographics
NPI:1518321645
Name:30TH AVENUE PHARMACY INC
Entity Type:Organization
Organization Name:30TH AVENUE PHARMACY INC
Other - Org Name:30TH AVENUE PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/TCH/AO
Authorized Official - Prefix:
Authorized Official - First Name:AREEJ
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDULLAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-777-8544
Mailing Address - Street 1:3506 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-4623
Mailing Address - Country:US
Mailing Address - Phone:718-777-8544
Mailing Address - Fax:718-777-8546
Practice Address - Street 1:3506 30TH AVE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-4623
Practice Address - Country:US
Practice Address - Phone:718-777-8544
Practice Address - Fax:718-777-8546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-05
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0344103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPENDINGMedicaid
2159780OtherPK