Provider Demographics
NPI:1740226125
Name:ELIZABETH PHARMACY INC
Entity Type:Organization
Organization Name:ELIZABETH PHARMACY INC
Other - Org Name:ELIZABETH PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-353-5948
Mailing Address - Street 1:13231 41ST AVE
Mailing Address - Street 2:UNIT 1B
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-3627
Mailing Address - Country:US
Mailing Address - Phone:718-353-5948
Mailing Address - Fax:718-353-5799
Practice Address - Street 1:13231 41ST AVE
Practice Address - Street 2:FLOOR 1
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-3627
Practice Address - Country:US
Practice Address - Phone:718-353-5948
Practice Address - Fax:718-353-5799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0275073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2710447Medicaid
2066274OtherPK
NY2710447Medicaid