Provider Demographics
NPI:1619419025
Name:PHARMACY AT THE WAVE, INC.
Entity Type:Organization
Organization Name:PHARMACY AT THE WAVE, INC.
Other - Org Name:PHARMACY AT THE WAVE INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SHPRINZES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-891-4300
Mailing Address - Street 1:104 W END AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-4952
Mailing Address - Country:US
Mailing Address - Phone:718-891-4300
Mailing Address - Fax:718-891-0009
Practice Address - Street 1:104 W END AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-4952
Practice Address - Country:US
Practice Address - Phone:718-891-4300
Practice Address - Fax:718-891-0009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-16
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
NY0350523336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166714OtherPK
2166714OtherPK