Provider Demographics
NPI:1104807346
Name:AMBA PHARMACY CORP
Entity type:Organization
Organization Name:AMBA PHARMACY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GERSTEN
Authorized Official - Suffix:
Authorized Official - Credentials:JD,RPH
Authorized Official - Phone:631-665-8660
Mailing Address - Street 1:753 COMMACK RD
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-7407
Mailing Address - Country:US
Mailing Address - Phone:631-665-8660
Mailing Address - Fax:631-666-6356
Practice Address - Street 1:753 COMMACK RD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-7407
Practice Address - Country:US
Practice Address - Phone:631-665-8660
Practice Address - Fax:631-666-6356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026845183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01592658Medicaid