Basic Information
| Provider Information | |||||||||
| NPI: | 1851372114 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUND SHORE PHARMACY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 N 7TH AVE | ||||||||
| Address2: | OUT-PATIENT PHARMACY | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105502026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9143711167 | ||||||||
| FaxNumber: | 9146640457 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 N 7TH AVE | ||||||||
| Address2: | OUT-PATIENT PHARMACY | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105502026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146648000 | ||||||||
| FaxNumber: | 9146640457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2005 | ||||||||
| LastUpdateDate: | 08/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | MAGALDI | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9143653975 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | RPH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 027010 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 02673045 | 05 | NY | MEDICAID | 027010 | 01 | NY | LICENSE | OTHER | BS9127742 | 01 | NY | DEA NUMBER | OTHER |