MEDICARE: ELLERY STREET PHARMACY INC

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	3336C0004X	Compounding Pharmacy
3	3336S0011X	Specialty Pharmacy
4	3336C0003X	Community/Retail Pharmacy	029503	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	2120855	OTHER		PK

General Provider Information

NPI Number	:	1912143686
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELLERY STREET PHARMACY INC

Provider Business Mailing Address
First Line	:	310 ELLERY ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11206-5312
Country	:	US
Telephone Number	:	718-782-9345
Fax Number	:	718-782-3839

Provider Business Practice Location Address
First Line	:	310 ELLERY ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11206-5312
Country	:	US
Telephone Number	:	718-782-9345
Fax Number	:	718-782-3839

Authorized Official
Title or Position	:	VICE PRESIDENT, AO
Name	:	HARINDER CHHABRA
Credential	:	RPH
Telephone Number	:	718-782-9345

Provider Enumeration Date	:	12/30/2008
Last Update Date	:	01/13/2017

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