Provider Demographics
NPI:1134366578
Name:1413 RX NY LLC
Entity type:Organization
Organization Name:1413 RX NY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-830-2522
Mailing Address - Street 1:1047 SURF AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-2810
Mailing Address - Country:US
Mailing Address - Phone:212-249-8202
Mailing Address - Fax:917-722-0851
Practice Address - Street 1:1456 FULTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-2505
Practice Address - Country:US
Practice Address - Phone:718-638-5088
Practice Address - Fax:718-228-5008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03056168Medicaid
2120017OtherPK