Provider Demographics
NPI:1508940768
Name:475 PHARMACY CORP
Entity Type:Organization
Organization Name:475 PHARMACY CORP
Other - Org Name:MCLEAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:WAI LAM
Authorized Official - Last Name:IP
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:914-963-0888
Mailing Address - Street 1:642 MCLEAN AVE
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10705-4740
Mailing Address - Country:US
Mailing Address - Phone:914-963-0888
Mailing Address - Fax:914-963-3879
Practice Address - Street 1:642 MCLEAN AVE
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10705-4740
Practice Address - Country:US
Practice Address - Phone:914-963-0888
Practice Address - Fax:914-963-3879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY16925183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00558205Medicaid