Provider Demographics
NPI:1063577674
Name:SR AND AG CORP
Entity type:Organization
Organization Name:SR AND AG CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SVETLANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-946-6899
Mailing Address - Street 1:250 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-1205
Mailing Address - Country:US
Mailing Address - Phone:718-946-6899
Mailing Address - Fax:718-946-2743
Practice Address - Street 1:250 KINGS HWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-1205
Practice Address - Country:US
Practice Address - Phone:718-946-6899
Practice Address - Fax:718-946-2743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01347575Medicaid
NY5070920001Medicare NSC