Provider Demographics
NPI:1255446282
Name:NYC AND EZY CORP
Entity type:Organization
Organization Name:NYC AND EZY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:REYCRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:763-479-1903
Mailing Address - Street 1:1500 HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLE PLAIN
Mailing Address - State:MN
Mailing Address - Zip Code:55359-9634
Mailing Address - Country:US
Mailing Address - Phone:763-479-1903
Mailing Address - Fax:763-479-6516
Practice Address - Street 1:1500 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:MAPLE PLAIN
Practice Address - State:MN
Practice Address - Zip Code:55359-9634
Practice Address - Country:US
Practice Address - Phone:763-479-1903
Practice Address - Fax:763-479-6516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MN2007193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2406127OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MN800760800Medicaid
0541660001Medicare NSC