Provider Demographics
NPI:1699857763
Name:SMP PHARMACY CORPORATION
Entity Type:Organization
Organization Name:SMP PHARMACY CORPORATION
Other - Org Name:KALISH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER SUPERVISING PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MADHUSUDAN
Authorized Official - Middle Name:I
Authorized Official - Last Name:PATNI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-641-5648
Mailing Address - Street 1:93 20 LIBERTY AVENUE
Mailing Address - Street 2:
Mailing Address - City:OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11417
Mailing Address - Country:US
Mailing Address - Phone:718-641-5648
Mailing Address - Fax:718-835-2064
Practice Address - Street 1:93 20 LIBERTY AVENUE
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11417
Practice Address - Country:US
Practice Address - Phone:718-641-5648
Practice Address - Fax:718-835-2064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016761333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00455601Medicaid
016761OtherNY LIC#
NY0697880001Medicare NSC