Basic Information
| Provider Information | |||||||||
| NPI: | 1174926406 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONG ISLAND JEWISH MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | VIVO HEALTH PHARMACY AT LONG ISLAND JEWISH MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 972 BRUSH HOLLOW RD FL 5 | ||||||||
| Address2: | |||||||||
| City: | WESTBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115901740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168766065 | ||||||||
| FaxNumber: | 5168765572 | ||||||||
| Practice Location | |||||||||
| Address1: | 270-05 76TH AVE | ||||||||
| Address2: | ATTN: VIVO HEALTH PHARMACY AT LIJ | ||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110401402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184708486 | ||||||||
| FaxNumber: | 7184705508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2014 | ||||||||
| LastUpdateDate: | 12/13/2017 | ||||||||
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| AuthorizedOfficialLastName: | CUSACK | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 5163216058 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LONG ISLAND JEWISH MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 032927 | NY | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 04133506 | 05 | NY | MEDICAID | 5811799 | 01 | NABP | OTHER |