MEDICARE: GOTHAM PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1093050445
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOTHAM PHARMACY INC

Provider Business Mailing Address
First Line	:	2258 3RD AVE
Second Line	:	(CORNER OF E 123RD ST AND 3RD AVE)
City	:	NEW YORK
State	:	NY
Zip	:	10035-2208
Country	:	US
Telephone Number	:	212-289-7800
Fax Number	:	212-289-7806

Provider Business Practice Location Address
First Line	:	2258 3RD AVE
Second Line	:	(CORNER OF E 123RD ST AND 3RD AVE)
City	:	NEW YORK
State	:	NY
Zip	:	10035-2208
Country	:	US
Telephone Number	:	212-289-7800
Fax Number	:	212-289-7806

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BETTY GRULLON
Credential	:
Telephone Number	:	347-739-2840

Provider Enumeration Date	:	12/11/2012
Last Update Date	:	09/23/2013

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Directions to “GOTHAM PHARMACY INC ” Practice Location

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