MEDICARE: TOWN DRUG AT BROADWAY 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	333600000X	Pharmacy
2	3336S0011X	Specialty Pharmacy
3	3336C0003X	Community/Retail Pharmacy	022829	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2060044	OTHER		PK

General Provider Information

NPI Number	:	1134140106
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOWN DRUG AT BROADWAY INC

Provider Business Mailing Address
First Line	:	4785 BROADWAY
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10034-4915
Country	:	US
Telephone Number	:	212-304-9582
Fax Number	:	212-304-9713

Provider Business Practice Location Address
First Line	:	4764 BROADWAY
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10034-4916
Country	:	US
Telephone Number	:	212-304-9582
Fax Number	:	212-304-9713

Authorized Official
Title or Position	:	VP
Name	:	SALVATORE PAGANO
Credential	:	R.PH.
Telephone Number	:	212-304-9582

Provider Enumeration Date	:	07/22/2006
Last Update Date	:	03/29/2023

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