Healthcare Provider Details

I. General information

NPI: 1902567738
Provider Name (Legal Business Name): OPRX #11776, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4747 NESCONSET HWY UNIT 10
PORT JEFFERSON STATION NY
11776-2866
US

IV. Provider business mailing address

4747 NESCONSET HWY UNIT 10
PORT JEFFERSON STATION NY
11776-2866
US

V. Phone/Fax

Practice location:
  • Phone: 631-474-7828
  • Fax: 631-474-7871
Mailing address:
  • Phone: 631-474-7828
  • Fax: 631-474-7871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SARIT ROY
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 516-876-0737