Provider Demographics
NPI:1306971114
Name:PROSPECT AVE. PHARMACY INC.
Entity type:Organization
Organization Name:PROSPECT AVE. PHARMACY INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:SYED
Authorized Official - Middle Name:A
Authorized Official - Last Name:MUZAFFAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-328-3593
Mailing Address - Street 1:993 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-2903
Mailing Address - Country:US
Mailing Address - Phone:718-328-3593
Mailing Address - Fax:718-328-3593
Practice Address - Street 1:993 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-2903
Practice Address - Country:US
Practice Address - Phone:718-328-3593
Practice Address - Fax:718-328-3593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0246323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02012077Medicaid
NY024632OtherNY PHARMACY LIC#
NY1323220001Medicare ID - Type Unspecified