Provider Demographics
NPI:1427138627
Name:MYRTLE AVE PHARMACY INC
Entity type:Organization
Organization Name:MYRTLE AVE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELIO
Authorized Official - Middle Name:P
Authorized Official - Last Name:LOMAGNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-596-0202
Mailing Address - Street 1:329 MYRTLE AVE
Mailing Address - Street 2:A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205
Mailing Address - Country:US
Mailing Address - Phone:718-596-0202
Mailing Address - Fax:718-596-6759
Practice Address - Street 1:329 MYRTLE AVE
Practice Address - Street 2:A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11205
Practice Address - Country:US
Practice Address - Phone:718-596-0202
Practice Address - Fax:718-596-6759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017606333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00733440Medicaid
NY3375412OtherNABP #
NY5115880001Medicare ID - Type Unspecified