Healthcare Provider Details

I. General information

NPI: 1487911368
Provider Name (Legal Business Name): JEFFERSON PHARMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2012
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3058 3RD AVE
BRONX NY
10451-4605
US

IV. Provider business mailing address

3058 3RD AVE
BRONX NY
10451-4605
US

V. Phone/Fax

Practice location:
  • Phone: 929-777-9108
  • Fax: 929-777-9109
Mailing address:
  • Phone: 929-777-9108
  • Fax: 929-777-9109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number031367
License Number StateNY

VIII. Authorized Official

Name: RAVINDER RAO ANNAMANENI
Title or Position: MEMBER
Credential:
Phone: 929-777-9108