Provider Demographics
NPI:1538252960
Name:424 NEIGHBORHOOD PHARMACY INC
Entity type:Organization
Organization Name:424 NEIGHBORHOOD PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:OLAKUNLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKARE
Authorized Official - Suffix:
Authorized Official - Credentials:BSC PHARMACY
Authorized Official - Phone:718-485-6303
Mailing Address - Street 1:424 SUTTER AVE
Mailing Address - Street 2:STORE 4
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-8113
Mailing Address - Country:US
Mailing Address - Phone:718-485-6303
Mailing Address - Fax:718-485-6292
Practice Address - Street 1:424 SUTTER AVE
Practice Address - Street 2:STORE 4
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-8113
Practice Address - Country:US
Practice Address - Phone:718-485-6303
Practice Address - Fax:718-485-6292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0264633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02530454Medicaid
2061690OtherPK
NY02530454Medicaid