Provider Demographics
NPI:1629444112
Name:ICON PHARMACY INC
Entity Type:Organization
Organization Name:ICON PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIT
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-886-3082
Mailing Address - Street 1:4173B BOWNE ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355
Mailing Address - Country:US
Mailing Address - Phone:718-886-3082
Mailing Address - Fax:718-886-3137
Practice Address - Street 1:4173B BOWNE ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355
Practice Address - Country:US
Practice Address - Phone:718-886-3082
Practice Address - Fax:718-886-3137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0338443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04353137Medicaid
NY04353137Medicaid