Provider Demographics
NPI:1144304270
Name:GLEN HEAD PHARMACY INC
Entity type:Organization
Organization Name:GLEN HEAD PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:VOHORA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:516-934-0095
Mailing Address - Street 1:699 GLEN COVE AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-1602
Mailing Address - Country:US
Mailing Address - Phone:516-676-1004
Mailing Address - Fax:516-676-5407
Practice Address - Street 1:699 GLEN COVE AVE
Practice Address - Street 2:
Practice Address - City:GLEN HEAD
Practice Address - State:NY
Practice Address - Zip Code:11545-1602
Practice Address - Country:US
Practice Address - Phone:516-676-1004
Practice Address - Fax:516-676-5407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00991084Medicaid
2064429OtherPK
NY0607970001Medicare NSC