Provider Demographics
NPI:1720184500
Name:AVON PHARMACY & SURGICAL INC
Entity Type:Organization
Organization Name:AVON PHARMACY & SURGICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-384-0630
Mailing Address - Street 1:82 GRAHAM AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-3311
Mailing Address - Country:US
Mailing Address - Phone:718-384-0630
Mailing Address - Fax:
Practice Address - Street 1:82 GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-3311
Practice Address - Country:US
Practice Address - Phone:718-384-0630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0231723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01718381Medicaid
NY5290270001Medicare ID - Type Unspecified