Provider Demographics
NPI:1649936980
Name:LIC PHARMACY CORP
Entity type:Organization
Organization Name:LIC PHARMACY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RONG TIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:YU
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:347-242-2981
Mailing Address - Street 1:4035 21ST ST STE 4C
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-6140
Mailing Address - Country:US
Mailing Address - Phone:347-242-2981
Mailing Address - Fax:347-242-2619
Practice Address - Street 1:4035 21ST ST STE 4C
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-6140
Practice Address - Country:US
Practice Address - Phone:347-242-2981
Practice Address - Fax:347-242-2619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy