Basic Information
| Provider Information | |||||||||
| NPI: | 1548587173 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EQUAL CARE III LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EQUAL CARE III LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4059 COLLEGE POINT BLVD | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113545140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188889338 | ||||||||
| FaxNumber: | 7188889299 | ||||||||
| Practice Location | |||||||||
| Address1: | 4059 COLLEGE POINT BLVD | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113545140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188889338 | ||||||||
| FaxNumber: | 7188889299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2010 | ||||||||
| LastUpdateDate: | 05/11/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | GABRIEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER/PIC | ||||||||
| AuthorizedOfficialTelephone: | 7188889338 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0004X | N | Suppliers | Pharmacy | Compounding Pharmacy | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | 030165 | NY | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 03245741 | 05 | NY | MEDICAID | 2125459 | 01 | PK | OTHER |