=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134140106
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOWN DRUG AT BROADWAY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2006
-----------------------------------------------------
Last Update Date | 03/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4764 BROADWAY
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10034-4916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-304-9582
-----------------------------------------------------
Fax | 212-304-9713
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4785 BROADWAY
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10034-4915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-304-9582
-----------------------------------------------------
Fax | 212-304-9713
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP
-----------------------------------------------------
Name | SALVATORE PAGANO
-----------------------------------------------------
Credential | R.PH.
-----------------------------------------------------
Telephone | 212-304-9582
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336S0011X
-----------------------------------------------------
Taxonomy Name | Specialty Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 022829
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------