Basic Information
| Provider Information | |||||||||
| NPI: | 1669971172 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MILL PARK DRUGS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ELTINGVILLE PHARMACY TOYS & GIFTS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3948 RICHMOND AVE | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103125111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183561789 | ||||||||
| FaxNumber: | 7183561777 | ||||||||
| Practice Location | |||||||||
| Address1: | 3948 RICHMOND AVE | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103125111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183561789 | ||||||||
| FaxNumber: | 7183561777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2018 | ||||||||
| LastUpdateDate: | 04/26/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MATTIOLI | ||||||||
| AuthorizedOfficialFirstName: | SILVANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/AO | ||||||||
| AuthorizedOfficialTelephone: | 7183561789 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0004X | 036468 | NY | Y | Suppliers | Pharmacy | Compounding Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 00337471 | 05 | NY | MEDICAID | 2176079 | 01 | PK | OTHER |