Provider Demographics
NPI:1598186595
Name:PHARMACY 112 INC.
Entity Type:Organization
Organization Name:PHARMACY 112 INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-475-4141
Mailing Address - Street 1:2608 ROUTE 112
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-2551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2608 ROUTE 112 # B
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2551
Practice Address - Country:US
Practice Address - Phone:631-438-0530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-18
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032401333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1598186595OtherNPI
NY032401OtherREGISTRATION
NY032401OtherREGISTRATION