Provider Demographics
NPI:1609086115
Name:SANDLANE PHARMACY CORP.
Entity Type:Organization
Organization Name:SANDLANE PHARMACY CORP.
Other - Org Name:NATES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:NATENZON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-556-3330
Mailing Address - Street 1:516 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-2446
Mailing Address - Country:US
Mailing Address - Phone:718-556-3330
Mailing Address - Fax:
Practice Address - Street 1:307 SAND LN
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-4500
Practice Address - Country:US
Practice Address - Phone:718-556-3330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0254863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02317917Medicaid
NY4633430001Medicare NSC