Provider Demographics
NPI:1013978865
Name:LAVIDA PHARMACY INC.
Entity Type:Organization
Organization Name:LAVIDA PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:TING CHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-426-2525
Mailing Address - Street 1:4034 82ND ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1305
Mailing Address - Country:US
Mailing Address - Phone:718-426-2525
Mailing Address - Fax:718-426-2523
Practice Address - Street 1:4034 82ND ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1305
Practice Address - Country:US
Practice Address - Phone:718-426-2525
Practice Address - Fax:718-426-2523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026192333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02422879Medicaid
NY02422879Medicaid