Provider Demographics
NPI:1992234454
Name:BLONDELL RX NY LLC
Entity type:Organization
Organization Name:BLONDELL RX NY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:MAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BASIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-819-5249
Mailing Address - Street 1:1047 SURF AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-2810
Mailing Address - Country:US
Mailing Address - Phone:212-249-8202
Mailing Address - Fax:
Practice Address - Street 1:1047 SURF AVE FL 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-2810
Practice Address - Country:US
Practice Address - Phone:718-819-5249
Practice Address - Fax:917-722-0851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-08
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
NY0359903336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05730387Medicaid