MEDICARE: JELUCA PHARMACY CORP

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	026254	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	3334771	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1467559385
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JELUCA PHARMACY CORP

Provider Business Mailing Address
First Line	:	811 N BROADWAY
Second Line	:
City	:	WHITE PLAINS
State	:	NY
Zip	:	10603-2400
Country	:	US
Telephone Number	:	914-949-6100
Fax Number	:	914-949-8630

Provider Business Practice Location Address
First Line	:	811 N BROADWAY
Second Line	:
City	:	WHITE PLAINS
State	:	NY
Zip	:	10603-2400
Country	:	US
Telephone Number	:	914-949-6100
Fax Number	:	914-949-8630

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JERRY MIRRA
Credential	:
Telephone Number	:	914-949-6100

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	03/23/2011

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Directions to “JELUCA PHARMACY CORP ” Practice Location

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