Provider Demographics
NPI:1366154288
Name:PEACH TREE PHARMACY INC
Entity type:Organization
Organization Name:PEACH TREE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:LISYANSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-320-1027
Mailing Address - Street 1:2492 ADAM CLAYTON POWELL JR BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-1340
Mailing Address - Country:US
Mailing Address - Phone:646-755-8262
Mailing Address - Fax:646-755-8263
Practice Address - Street 1:2492 ADAM CLAYTON POWELL JR BLVD
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10030-1340
Practice Address - Country:US
Practice Address - Phone:646-755-8262
Practice Address - Fax:646-755-8263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-22
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY039982OtherNYS BOARD OF PHARMACY