Provider Demographics
NPI:1730286675
Name:AC NORTHERN LLC
Entity Type:Organization
Organization Name:AC NORTHERN LLC
Other - Org Name:AC NORTHERN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KI JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-886-0060
Mailing Address - Street 1:15416 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5030
Mailing Address - Country:US
Mailing Address - Phone:718-886-0060
Mailing Address - Fax:718-886-0061
Practice Address - Street 1:15416 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5030
Practice Address - Country:US
Practice Address - Phone:718-886-0060
Practice Address - Fax:718-886-0061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0272943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02672773Medicaid
2064717OtherPK
5481730001Medicare NSC
5481730001Medicare NSC