Provider Demographics
NPI:1912184193
Name:NEW STAGE PHARMACY INC
Entity Type:Organization
Organization Name:NEW STAGE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KHOSROW
Authorized Official - Middle Name:G
Authorized Official - Last Name:MOGHADDAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-465-2121
Mailing Address - Street 1:20419 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-2213
Mailing Address - Country:US
Mailing Address - Phone:516-658-6854
Mailing Address - Fax:
Practice Address - Street 1:20419 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-2213
Practice Address - Country:US
Practice Address - Phone:516-658-6854
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10520183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00261789Medicaid