Provider Demographics
NPI:1295299535
Name:4TH AVE DRUG STORE INC
Entity type:Organization
Organization Name:4TH AVE DRUG STORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BIBI
Authorized Official - Middle Name:
Authorized Official - Last Name:ESAHACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-863-0399
Mailing Address - Street 1:26 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-3105
Mailing Address - Country:US
Mailing Address - Phone:914-863-0399
Mailing Address - Fax:914-863-0397
Practice Address - Street 1:26 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-3105
Practice Address - Country:US
Practice Address - Phone:914-863-0399
Practice Address - Fax:914-863-0397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-30
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy