Provider Demographics
NPI:1639534167
Name:ELLNER PLAZA II CORP
Entity Type:Organization
Organization Name:ELLNER PLAZA II CORP
Other - Org Name:MAIN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:LATAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-261-5608
Mailing Address - Street 1:7271 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-2407
Mailing Address - Country:US
Mailing Address - Phone:718-261-5608
Mailing Address - Fax:718-261-5867
Practice Address - Street 1:7271 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-2407
Practice Address - Country:US
Practice Address - Phone:718-261-5608
Practice Address - Fax:718-261-5867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-29
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0343403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160178OtherPK