Provider Demographics
NPI:1063755098
Name:MILLBROOK PHARMACY LLC
Entity type:Organization
Organization Name:MILLBROOK PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NOOR
Authorized Official - Middle Name:FATIMA
Authorized Official - Last Name:AMJAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-677-3131
Mailing Address - Street 1:3272 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:12545-5975
Mailing Address - Country:US
Mailing Address - Phone:845-677-3131
Mailing Address - Fax:845-677-3111
Practice Address - Street 1:3272 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:MILLBROOK
Practice Address - State:NY
Practice Address - Zip Code:12545-5975
Practice Address - Country:US
Practice Address - Phone:845-677-3131
Practice Address - Fax:845-677-3111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-28
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
NY0318473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139759OtherPK
2139759OtherPK