Provider Demographics
NPI:1285724534
Name:EAST ISLIP PHARMACY INC
Entity type:Organization
Organization Name:EAST ISLIP PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VENKAT
Authorized Official - Middle Name:
Authorized Official - Last Name:DANDAMUDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-581-9620
Mailing Address - Street 1:126 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-2600
Mailing Address - Country:US
Mailing Address - Phone:631-581-9620
Mailing Address - Fax:631-581-9410
Practice Address - Street 1:126 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-2600
Practice Address - Country:US
Practice Address - Phone:631-581-9620
Practice Address - Fax:631-581-9410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-14
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0337553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04223896Medicaid
2153291OtherPK
NY04223896Medicaid