Provider Demographics
NPI:1851007694
Name:ESCRIPT360 SOUTH STREET LLC
Entity Type:Organization
Organization Name:ESCRIPT360 SOUTH STREET LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:YURIY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVYDOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-604-0712
Mailing Address - Street 1:5 PENNY POND CT
Mailing Address - Street 2:
Mailing Address - City:GREENVALE
Mailing Address - State:NY
Mailing Address - Zip Code:11548-1400
Mailing Address - Country:US
Mailing Address - Phone:646-633-2170
Mailing Address - Fax:516-492-3356
Practice Address - Street 1:601 S 10TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-1917
Practice Address - Country:US
Practice Address - Phone:267-635-4576
Practice Address - Fax:267-635-4577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-25
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPP482848OtherPHARMACY LICENSE