Provider Demographics
NPI:1619045416
Name:1746 PHARMACY CORP
Entity Type:Organization
Organization Name:1746 PHARMACY CORP
Other - Org Name:CLARKSON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:MOIN
Authorized Official - Middle Name:
Authorized Official - Last Name:UDDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-774-1656
Mailing Address - Street 1:524 CLARKSON AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2015
Mailing Address - Country:US
Mailing Address - Phone:718-774-1656
Mailing Address - Fax:718-774-5636
Practice Address - Street 1:524 CLARKSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2015
Practice Address - Country:US
Practice Address - Phone:718-774-1656
Practice Address - Fax:718-774-5636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0165913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01602395Medicaid
2060576OtherPK
NY01602395Medicaid