Provider Demographics
NPI:1316955537
Name:TRADITIONAL PHARMACY INC
Entity type:Organization
Organization Name:TRADITIONAL PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUP PHARM AND PRT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATALYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERKOWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-787-2300
Mailing Address - Street 1:1206 AVENUE M
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-5204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1206 AVENUE M
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-5204
Practice Address - Country:US
Practice Address - Phone:718-787-2300
Practice Address - Fax:718-382-3988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027341333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02689265Medicaid
3346548OtherOTHER ID NUMBER-COMMERCIAL NUMBER
5521350001Medicare ID - Type Unspecified