Provider Demographics
NPI:1659515583
Name:IRVING PHARMACY CORP.
Entity Type:Organization
Organization Name:IRVING PHARMACY CORP.
Other - Org Name:IRVING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GIOVANNI
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-848-1120
Mailing Address - Street 1:118 WYCKOFF AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-8069
Mailing Address - Country:US
Mailing Address - Phone:718-484-8510
Mailing Address - Fax:718-484-8508
Practice Address - Street 1:118 WYCKOFF AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-8069
Practice Address - Country:US
Practice Address - Phone:718-484-8510
Practice Address - Fax:718-484-8508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-22
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0294273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03111442Medicaid
NY6359530001Medicare NSC