Provider Demographics
NPI:1629347414
Name:REVIVAL PHARMACY LLC
Entity Type:Organization
Organization Name:REVIVAL PHARMACY LLC
Other - Org Name:CITYWIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MOSHE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOSKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-298-2222
Mailing Address - Street 1:5359B KINGS HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203
Mailing Address - Country:US
Mailing Address - Phone:718-298-2222
Mailing Address - Fax:718-298-3333
Practice Address - Street 1:5369 KINGS HWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-6704
Practice Address - Country:US
Practice Address - Phone:718-298-2222
Practice Address - Fax:718-298-3333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-22
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RO00134300333600000X
NY0309913336C0003X
PANP0008063336L0003X
CT00031913336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103260623Medicaid
2134031OtherPK
NY03398001Medicaid
NY03398001Medicaid