Provider Demographics
NPI:1346226891
Name:MIDRAG NINE PHARMACY INC
Entity type:Organization
Organization Name:MIDRAG NINE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRESSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-948-4141
Mailing Address - Street 1:417 TARRYTOWN RD
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10607-1423
Mailing Address - Country:US
Mailing Address - Phone:914-948-4141
Mailing Address - Fax:914-948-7559
Practice Address - Street 1:417 TARRYTOWN ROAD
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10607
Practice Address - Country:US
Practice Address - Phone:914-948-4141
Practice Address - Fax:914-948-7559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023767333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01927206Medicaid
NY5285390001Medicare NSC