Provider Demographics
NPI:1184903650
Name:OLD FAMILY PHARMACY INC
Entity type:Organization
Organization Name:OLD FAMILY PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:GENIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-339-3500
Mailing Address - Street 1:1917 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1313
Mailing Address - Country:US
Mailing Address - Phone:718-339-3500
Mailing Address - Fax:718-998-2280
Practice Address - Street 1:1917 KINGS HWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1313
Practice Address - Country:US
Practice Address - Phone:718-339-3500
Practice Address - Fax:718-998-2280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0310423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY031042Medicaid
2133970OtherPK