Provider Demographics
NPI:1689701484
Name:LONGEVITY PHARMACY LLC
Entity Type:Organization
Organization Name:LONGEVITY PHARMACY LLC
Other - Org Name:FUZHOU PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ROMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:FUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-693-8866
Mailing Address - Street 1:96 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-7031
Mailing Address - Country:US
Mailing Address - Phone:212-693-8866
Mailing Address - Fax:815-425-8920
Practice Address - Street 1:96 E BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-7031
Practice Address - Country:US
Practice Address - Phone:212-693-8866
Practice Address - Fax:815-425-8920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0287883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2949604Medicaid
2063778OtherPK
NY2949604Medicaid