Provider Demographics
NPI:1710117627
Name:LA HISPANA ON BROADWAY PHARMACY LLC
Entity Type:Organization
Organization Name:LA HISPANA ON BROADWAY PHARMACY LLC
Other - Org Name:LA HISPANA ON BROADWAY PHARMACY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:SEIDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-375-4464
Mailing Address - Street 1:3890 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1509
Mailing Address - Country:US
Mailing Address - Phone:212-568-6878
Mailing Address - Fax:212-568-6877
Practice Address - Street 1:3890 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1509
Practice Address - Country:US
Practice Address - Phone:212-568-6878
Practice Address - Fax:212-568-6877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-27
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0294883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3361932OtherNCPDP PROVIDER IDENTIFICATION NUMBER