Provider Demographics
NPI:1013080209
Name:LOUIS PHARMACY INC.
Entity Type:Organization
Organization Name:LOUIS PHARMACY INC.
Other - Org Name:CITY LINE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, PIC
Authorized Official - Prefix:
Authorized Official - First Name:JOBY
Authorized Official - Middle Name:
Authorized Official - Last Name:NELLICKEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-324-0555
Mailing Address - Street 1:4704 WHITE PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10470-1103
Mailing Address - Country:US
Mailing Address - Phone:718-324-0555
Mailing Address - Fax:718-324-4574
Practice Address - Street 1:4704 WHITE PLAINS RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10470-1103
Practice Address - Country:US
Practice Address - Phone:718-324-0555
Practice Address - Fax:718-324-4574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0265133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02501164Medicaid
NY3371426OtherNCPDP
NY02501164Medicaid