MEDICARE: DERU PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	020810	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3397583	OTHER		OTHER ID NUMBER

General Provider Information

NPI Number	:	1134288863
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERU PHARMACY

Provider Business Mailing Address
First Line	:	5915 AVENUE N
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-4129
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5915 AVENUE N
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-4129
Country	:	US
Telephone Number	:	718-209-2222
Fax Number	:	718-209-9489

Authorized Official
Title or Position	:	PRESIDENT
Name	:	NICHOLAS DELLORUSSO
Credential	:
Telephone Number	:	718-209-2222

Provider Enumeration Date	:	12/08/2006
Last Update Date	:	03/21/2008

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