Provider Demographics
NPI:1770858680
Name:TRIBORO PHARMACY
Entity Type:Organization
Organization Name:TRIBORO PHARMACY
Other - Org Name:TRIBORO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ATHANASATOS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:917-865-7754
Mailing Address - Street 1:3720 DITMARS BLVD
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-1841
Mailing Address - Country:US
Mailing Address - Phone:718-777-7033
Mailing Address - Fax:718-777-7038
Practice Address - Street 1:3720 DITMARS BLVD
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-1841
Practice Address - Country:US
Practice Address - Phone:718-777-7033
Practice Address - Fax:718-777-7038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-12
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0312633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03455465Medicaid
2134928OtherPK
2134928OtherPK