Basic Information
| Provider Information | |||||||||
| NPI: | 1871024455 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LONG ISLAND JEWISH MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | VIVO HEALTH PHARMACY AT ZUCKER HILLSIDE HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 7559 263RD ST | ||||||||
| Address2: | VIVO HEALTH PHARMACY AT ZUCKER HILLSIDE HOSPITAL | ||||||||
| City: | GLEN OAKS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110041150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184705611 | ||||||||
| FaxNumber: | 7184705612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2017 | ||||||||
| LastUpdateDate: | 04/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | CUSACK | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT & CFO | ||||||||
| AuthorizedOfficialTelephone: | 5163216058 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336S0011X | N | Suppliers | Pharmacy | Specialty Pharmacy | 3336C0003X | 035154 | NY | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2168601 | 01 | PK | OTHER |