Provider Demographics
NPI:1225870090
Name:GRASSY SPRAIN PHARMACY,INC
Entity type:Organization
Organization Name:GRASSY SPRAIN PHARMACY,INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:CIARLETTA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:914-779-5133
Mailing Address - Street 1:640 TUCKAHOE RD
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10710-5705
Mailing Address - Country:US
Mailing Address - Phone:914-779-5133
Mailing Address - Fax:914-779-8202
Practice Address - Street 1:640 TUCKAHOE RD
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10710-5705
Practice Address - Country:US
Practice Address - Phone:914-779-5133
Practice Address - Fax:914-779-8202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY017779OtherNYS BOARD OF PHARMACY LICENSE
NY01741340Medicaid