Provider Demographics
NPI:1568550333
Name:12116 LIBERTY AVENUE DRUGS INC.
Entity Type:Organization
Organization Name:12116 LIBERTY AVENUE DRUGS INC.
Other - Org Name:CPW PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:SHANAZ
Authorized Official - Last Name:BACCHUS-QUDDUS
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:718-322-4900
Mailing Address - Street 1:12116 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11419-2112
Mailing Address - Country:US
Mailing Address - Phone:718-322-4900
Mailing Address - Fax:718-322-3121
Practice Address - Street 1:12116 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11419-2112
Practice Address - Country:US
Practice Address - Phone:718-322-4900
Practice Address - Fax:718-322-3121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027272183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02673476Medicaid
NY02673476Medicaid