Provider Demographics
NPI:1396748810
Name:MAPLE AVE PHARMACY INC
Entity type:Organization
Organization Name:MAPLE AVE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ISREAL
Authorized Official - Middle Name:MEILECH
Authorized Official - Last Name:WEISSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-774-1464
Mailing Address - Street 1:48 BAKERTOWN ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950
Mailing Address - Country:US
Mailing Address - Phone:845-774-1464
Mailing Address - Fax:845-774-1454
Practice Address - Street 1:48 BAKERTOWN ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950
Practice Address - Country:US
Practice Address - Phone:845-774-1464
Practice Address - Fax:845-774-1454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-30
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027013333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02638668Medicaid
NY02638668Medicaid