Provider Demographics
NPI:1982637666
Name:SANTA FE PHARMACY INC
Entity Type:Organization
Organization Name:SANTA FE PHARMACY INC
Other - Org Name:SANTA FE PHARMACY INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:NISSREN
Authorized Official - Middle Name:K
Authorized Official - Last Name:GADELRAB
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-651-7400
Mailing Address - Street 1:8831 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-7736
Mailing Address - Country:US
Mailing Address - Phone:718-651-7400
Mailing Address - Fax:718-651-1777
Practice Address - Street 1:8831 37TH AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7736
Practice Address - Country:US
Practice Address - Phone:718-651-7400
Practice Address - Fax:718-651-1777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0261533336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02461549Medicaid
NY4991410001Medicare ID - Type Unspecified