MEDICARE: CROTONA 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	3336C0004X	Compounding Pharmacy
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	333600000X	Pharmacy
4	3336C0003X	Community/Retail Pharmacy	031218	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5805164	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1831458702
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROTONA PHARMACY CORP

Provider Business Mailing Address
First Line	:	1384 BOSTON RD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10456-2541
Country	:	US
Telephone Number	:	917-688-1102
Fax Number	:	917-688-1104

Provider Business Practice Location Address
First Line	:	1384 BOSTON RD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10456-2541
Country	:	US
Telephone Number	:	917-688-1102
Fax Number	:	917-688-1104

Authorized Official
Title or Position	:	OFFICER
Name	:	ROBERT FORKOSH
Credential	:
Telephone Number	:	347-204-5001

Provider Enumeration Date	:	05/11/2012
Last Update Date	:	07/16/2012

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Directions to “CROTONA PHARMACY CORP ” Practice Location

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