Basic Information
| Provider Information | |||||||||
| NPI: | 1578550729 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOMS PHARMACY INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | MOMS PHARMACY INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 637302 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315476520 | ||||||||
| FaxNumber: | 2062024127 | ||||||||
| Practice Location | |||||||||
| Address1: | 45 MELVILLE PARK RD | ||||||||
| Address2: | |||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117473109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315476520 | ||||||||
| FaxNumber: | 6312495865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 05/09/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FICHERA | ||||||||
| AuthorizedOfficialFirstName: | RUSS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR VP, CFO | ||||||||
| AuthorizedOfficialTelephone: | 6318705126 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | 021158 | NY | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 02533719 | 05 | NY | MEDICAID | 3323324 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER | 0023990 | 05 | NJ | MEDICAID | 003111672 | 05 | CT | MEDICAID |