Provider Demographics
NPI:1962823567
Name:KSYRX LLC
Entity Type:Organization
Organization Name:KSYRX LLC
Other - Org Name:MAKO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:IBRAHIM
Authorized Official - Middle Name:
Authorized Official - Last Name:SYLLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-696-9146
Mailing Address - Street 1:PO BOX 958277
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30095-9539
Mailing Address - Country:US
Mailing Address - Phone:281-755-4922
Mailing Address - Fax:470-299-3159
Practice Address - Street 1:5050 JIMMY CARTER BLVD STE 350A
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-2759
Practice Address - Country:US
Practice Address - Phone:770-696-9146
Practice Address - Fax:470-299-3159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-27
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X
GAPHHH0000603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2143584OtherPK