Provider Demographics
NPI:1669913992
Name:ROOSEVELT CITY PHARMACY INC
Entity type:Organization
Organization Name:ROOSEVELT CITY PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HAIYING
Authorized Official - Middle Name:
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-255-1065
Mailing Address - Street 1:7918 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-6717
Mailing Address - Country:US
Mailing Address - Phone:718-255-1065
Mailing Address - Fax:718-255-6734
Practice Address - Street 1:7918 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-6717
Practice Address - Country:US
Practice Address - Phone:718-255-1065
Practice Address - Fax:718-255-6734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-20
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
NY035296333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168619OtherPK