=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831238880
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROSCRIPT PHARMACY MGMT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2007
-----------------------------------------------------
Last Update Date | 06/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1441 SOUTH AVE STE 703
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10314-3784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-646-1780
-----------------------------------------------------
Fax | 347-897-4660
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1441 SOUTH AVE STE 703
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10314-3784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | GINA DEBARTOLOME
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 347-897-4670
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336M0002X
-----------------------------------------------------
Taxonomy Name | Mail Order Pharmacy
-----------------------------------------------------
License Number | 026894
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------