Provider Demographics
NPI:1609804269
Name:STONY BROOK PHARMACY
Entity Type:Organization
Organization Name:STONY BROOK PHARMACY
Other - Org Name:MEDICAL PARK DRUG AND SURGICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAX
Authorized Official - Middle Name:
Authorized Official - Last Name:SALVATORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-751-4477
Mailing Address - Street 1:2500 NESCONSET HWY
Mailing Address - Street 2:STE 3 A
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2555
Mailing Address - Country:US
Mailing Address - Phone:631-751-4477
Mailing Address - Fax:631-751-4962
Practice Address - Street 1:2500 NESCONSET HWY
Practice Address - Street 2:STE 3 A
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2555
Practice Address - Country:US
Practice Address - Phone:631-751-4477
Practice Address - Fax:631-751-4962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0184643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2063472OtherPK
NY00890780Medicaid
NY00890780Medicaid