MEDICARE: BLONDELL RX NY LLC

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	3336L0003X	Long Term Care Pharmacy

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

General Provider Information

NPI Number	:	1992234454
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLONDELL RX NY LLC

Provider Business Mailing Address
First Line	:	1047 SURF AVE FL 2
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11224-2810
Country	:	US
Telephone Number	:	212-249-8202
Fax Number	:

Provider Business Practice Location Address
First Line	:	1047 SURF AVE FL 2
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11224-2810
Country	:	US
Telephone Number	:	718-819-5249
Fax Number	:	917-722-0851

Authorized Official
Title or Position	:	PIC
Name	:	MAYA BASIN
Credential	:
Telephone Number	:	718-819-5249

Provider Enumeration Date	:	06/08/2017
Last Update Date	:	10/04/2023

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Directions to “BLONDELL RX NY LLC ” Practice Location

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