Provider Demographics
NPI:1922040716
Name:LISCIO PHARMACY CORP
Entity Type:Organization
Organization Name:LISCIO PHARMACY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:GROSSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-547-3706
Mailing Address - Street 1:43 BIRCHWOOD LN
Mailing Address - Street 2:
Mailing Address - City:HARTSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10530-3124
Mailing Address - Country:US
Mailing Address - Phone:914-328-0043
Mailing Address - Fax:718-231-3919
Practice Address - Street 1:2498 WILLIAMSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-4806
Practice Address - Country:US
Practice Address - Phone:718-547-3706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0087743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00260426Medicaid
NY5343950001Medicare NSC