Basic Information
| Provider Information | |||||||||
| NPI: | 1629054325 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WSNCHS EAST INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTH OAKS HOSPITAL BROADLAWN MANOR NCC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 SUNRISE HWY | ||||||||
| Address2: | |||||||||
| City: | AMITYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312644000 | ||||||||
| FaxNumber: | 6316085700 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 SUNRISE HWY | ||||||||
| Address2: | |||||||||
| City: | AMITYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312644000 | ||||||||
| FaxNumber: | 6316085700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DREZEN | ||||||||
| AuthorizedOfficialFirstName: | WARREN | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHARMACY | ||||||||
| AuthorizedOfficialTelephone: | 6312644000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | REGISTERED PHARMACIS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 024571 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 01660842 | 05 | NY | MEDICAID |