Provider Demographics
NPI:1205963972
Name:MONTEFIORE MEDICAL CENTER-MONTEFIORE PHARMACY
Entity type:Organization
Organization Name:MONTEFIORE MEDICAL CENTER-MONTEFIORE PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-920-4300
Mailing Address - Street 1:111 E 210TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2401
Mailing Address - Country:US
Mailing Address - Phone:718-920-5194
Mailing Address - Fax:718-652-0733
Practice Address - Street 1:3444 KOSSUTH AVE
Practice Address - Street 2:GROUND FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2410
Practice Address - Country:US
Practice Address - Phone:718-920-4300
Practice Address - Fax:718-652-0733
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MONTEFIORE MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-28
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0004753336I0012X, 3336C0002X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY032128OtherPHARMACY LICENSE