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Provider Information for 1811903594


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HAVEN PHARMACY

Other Names:  
Doing Business As: 
PANACEA PHARMACY

Organization Subpart: NO

NPI: 1811903594
Last Updated: 2009-09-30
Certification Date:

Details

NameValue
NPI1811903594
Enumeration Date2006-08-01
NPI TypeNPI-2 Organization
StatusActive
Authorized Official Information Name: VIKTORIA GRINBLAT
Title: RPH, SP, SECRETARY
Phone: 7183829616
Mailing Address 1211 AVENUE U
BROOKLYN, NY 11229-4108
United States

Phone: 718-382-9616 | Fax:718-382-9615
 
Primary Practice Address 1211 AVENUE U
BROOKLYN, NY 11229-4108
United States

Phone: 718-382-9616 | Fax:718-382-9615
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
MEDICAIDNY02384316
Other (non-Medicare)NY3331307NCPDP
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
Yes 3336C0003X - Pharmacy - Community/Retail PharmacyNY025828