Provider Demographics
NPI:1710117908
Name:HEALTH SOURCE PLUS PHARMACY, LLC.
Entity Type:Organization
Organization Name:HEALTH SOURCE PLUS PHARMACY, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:EMMA
Authorized Official - Middle Name:
Authorized Official - Last Name:KALONTAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-849-6700
Mailing Address - Street 1:11807 METROPOLITAN AVE
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-2020
Mailing Address - Country:US
Mailing Address - Phone:718-849-6700
Mailing Address - Fax:718-849-1659
Practice Address - Street 1:11807 METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-2020
Practice Address - Country:US
Practice Address - Phone:718-849-6700
Practice Address - Fax:718-849-1659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-22
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0297013336C0003X, 3336L0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3123053Medicaid
2122230OtherPK