Provider Demographics
NPI:1881128569
Name:LACONIA AVENUE PHARMACY CORP
Entity type:Organization
Organization Name:LACONIA AVENUE PHARMACY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ANOKYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-332-8533
Mailing Address - Street 1:4041 LACONIA AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-4917
Mailing Address - Country:US
Mailing Address - Phone:347-843-7747
Mailing Address - Fax:347-843-7748
Practice Address - Street 1:4041 LACONIA AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-4917
Practice Address - Country:US
Practice Address - Phone:347-843-7747
Practice Address - Fax:347-843-7748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-19
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2168990OtherPK