Provider Demographics
NPI:1427130210
Name:3340 BROADWAY PHARMACY 2 INC
Entity type:Organization
Organization Name:3340 BROADWAY PHARMACY 2 INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-926-9800
Mailing Address - Street 1:3621 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-2518
Mailing Address - Country:US
Mailing Address - Phone:212-926-9800
Mailing Address - Fax:212-926-2228
Practice Address - Street 1:3621 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-2518
Practice Address - Country:US
Practice Address - Phone:212-926-9800
Practice Address - Fax:212-926-2228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0270323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2063653OtherPK
NY02648108Medicaid
NY02648108Medicaid