Provider Demographics
NPI:1770678666
Name:PEG APOTHECARY INC
Entity Type:Organization
Organization Name:PEG APOTHECARY INC
Other - Org Name:EMERALD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:SHAWN
Authorized Official - Last Name:NEALIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-944-0862
Mailing Address - Street 1:4295 KATONAH AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10470
Mailing Address - Country:US
Mailing Address - Phone:718-944-0862
Mailing Address - Fax:718-944-0864
Practice Address - Street 1:4295 KATONAH AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10470
Practice Address - Country:US
Practice Address - Phone:718-944-0862
Practice Address - Fax:718-944-0864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047516183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00290857Medicaid
NY025341OtherNYS PHARMACY LIC
NY3325835OtherNABP
NY3325835OtherNABP
NY00290857Medicaid