Healthcare Provider Details

I. General information

NPI: 1124833942
Provider Name (Legal Business Name): 3801 BROADWAY RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2025
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 BROADWAY
NEW YORK NY
10032-1566
US

IV. Provider business mailing address

3801 BROADWAY
NEW YORK NY
10032-1566
US

V. Phone/Fax

Practice location:
  • Phone: 212-540-3801
  • Fax: 212-540-3802
Mailing address:
  • Phone: 212-540-3801
  • Fax: 212-540-3802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MIRIAM RAKHMANOVA
Title or Position: PRESIDENT
Credential:
Phone: 212-540-3801