Healthcare Provider Details

I. General information

NPI: 1053308684
Provider Name (Legal Business Name): MARTIN DRUGS OF RIVERHEAD,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

849 OLD COUNTRY RD
RIVERHEAD NY
11901-2106
US

IV. Provider business mailing address

849 OLD COUNTRY RD
RIVERHEAD NY
11901-2106
US

V. Phone/Fax

Practice location:
  • Phone: 631-727-0550
  • Fax: 631-727-3054
Mailing address:
  • Phone: 631-727-0550
  • Fax: 631-727-3054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number019246
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. RAJENDRAPRASAD VENIGALLA
Title or Position: OWNER PRES
Credential: RPH
Phone: 347-528-8893