Provider Demographics
NPI:1336521988
Name:LIVONIA PHARMACY INC
Entity Type:Organization
Organization Name:LIVONIA PHARMACY INC
Other - Org Name:LIVONIA PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT,OWNER,AO
Authorized Official - Prefix:
Authorized Official - First Name:IMRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-484-8100
Mailing Address - Street 1:625A LIVONIA AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207
Mailing Address - Country:US
Mailing Address - Phone:718-484-8100
Mailing Address - Fax:718-484-8103
Practice Address - Street 1:625A LIVONIA AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-5301
Practice Address - Country:US
Practice Address - Phone:718-484-8100
Practice Address - Fax:718-484-8103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-19
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
NY0336143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152912OtherPK
NY7575050001Medicare NSC