=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366683021
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELMHURST STAR PHARMACY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2009
-----------------------------------------------------
Last Update Date | 12/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1850 GRAND CONCOURSE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10457-5520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-299-2200
-----------------------------------------------------
Fax | 718-299-6200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1850 GRAND CONCOURSE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10457-5520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-299-2200
-----------------------------------------------------
Fax | 718-299-6900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SATYA DASARI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-229-2200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 029299
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------