Provider Demographics
NPI:1972827103
Name:LISCIO PHARMA INC
Entity Type:Organization
Organization Name:LISCIO PHARMA INC
Other - Org Name:LISCIO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER / VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DULAL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAKRABORTY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-547-3706
Mailing Address - Street 1:2498 WILLIAMSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-4897
Mailing Address - Country:US
Mailing Address - Phone:718-547-3706
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:718-231-3919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-17
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0300273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2125131OtherPK
NY03193804Medicaid
NY03193804Medicaid
5800164OtherNCPDP PROVIDER IDENTIFICATION NUMBER
6449310001Medicare NSC