Provider Demographics
NPI:1982940763
Name:STATEN ISLAND PHARMACY INC.
Entity Type:Organization
Organization Name:STATEN ISLAND PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:NICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEGAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:718-448-5200
Mailing Address - Street 1:1807 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3515
Mailing Address - Country:US
Mailing Address - Phone:718-448-5200
Mailing Address - Fax:
Practice Address - Street 1:1807 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3515
Practice Address - Country:US
Practice Address - Phone:718-448-5200
Practice Address - Fax:718-448-5311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-23
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03548143Medicaid