Provider Demographics
NPI:1609942614
Name:CASTLETON PHARMACY CORP
Entity Type:Organization
Organization Name:CASTLETON PHARMACY CORP
Other - Org Name:NATES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:NATENZON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-734-4662
Mailing Address - Street 1:516 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-2804
Mailing Address - Country:US
Mailing Address - Phone:718-720-3710
Mailing Address - Fax:718-720-6135
Practice Address - Street 1:252 PORT RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-1749
Practice Address - Country:US
Practice Address - Phone:718-720-5600
Practice Address - Fax:718-720-5612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0298463336C0003X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3360308OtherNABP
NY03135297Medicaid