Provider Demographics
NPI:1487709598
Name:KISSENA DRUGS AND SURGICAL SUPPLY INC
Entity type:Organization
Organization Name:KISSENA DRUGS AND SURGICAL SUPPLY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD AND RPH
Authorized Official - Phone:718-793-7658
Mailing Address - Street 1:72 63 KISSENA BLVD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367
Mailing Address - Country:US
Mailing Address - Phone:718-793-7658
Mailing Address - Fax:718-793-0576
Practice Address - Street 1:72 63 KISSENA BLVD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367
Practice Address - Country:US
Practice Address - Phone:718-793-7658
Practice Address - Fax:718-793-0576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
NY0271163336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02618624Medicaid
3318513OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5410820001Medicare NSC