Provider Demographics
NPI:1902940307
Name:FIVE STAR PHARMACY INC
Entity Type:Organization
Organization Name:FIVE STAR PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOFIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-686-8900
Mailing Address - Street 1:4125 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-5709
Mailing Address - Country:US
Mailing Address - Phone:718-686-8900
Mailing Address - Fax:718-686-8910
Practice Address - Street 1:4125 18TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-5709
Practice Address - Country:US
Practice Address - Phone:718-686-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-18
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5910110001Medicare NSC