Provider Demographics
NPI:1528041175
Name:PALM-GATE PHARMACY
Entity Type:Organization
Organization Name:PALM-GATE PHARMACY
Other - Org Name:GATES-PALMETTO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUR REGISTERED PHARMACIST SUPERVISI
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH SP
Authorized Official - Phone:718-381-6084
Mailing Address - Street 1:583 KNICKERBOCKER AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-4742
Mailing Address - Country:US
Mailing Address - Phone:718-381-6084
Mailing Address - Fax:718-418-2263
Practice Address - Street 1:583 KNICKERBOCKER AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-4742
Practice Address - Country:US
Practice Address - Phone:718-381-6084
Practice Address - Fax:718-418-2263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014376333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3326217OtherNABP
NY00259334Medicaid
NY3326217OtherNABP