Provider Demographics
NPI:1780771980
Name:QUEENS PHARMACY CORP
Entity type:Organization
Organization Name:QUEENS PHARMACY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SP/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIROCHINSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-934-3838
Mailing Address - Street 1:1653 SHEEPSHEAD BAY RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-3804
Mailing Address - Country:US
Mailing Address - Phone:718-934-3838
Mailing Address - Fax:718-648-9457
Practice Address - Street 1:1653 SHEEPSHEAD BAY RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3804
Practice Address - Country:US
Practice Address - Phone:718-934-3838
Practice Address - Fax:718-648-9457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0244303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01998750Medicaid
2058837OtherPK
1306810001Medicare NSC