MEDICARE: 21 AVE PHARMACY & MEDICAL SUPPLY 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	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1259801-DCA	OTHER	NY	NY STATE DEPARTMENT OF CONSUMER AFFAIRS

General Provider Information

NPI Number	:	1144843566
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	21 AVE PHARMACY & MEDICAL SUPPLY INC.

Provider Business Mailing Address
First Line	:	8511 21ST AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11214-3207
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8511 21ST AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11214-3207
Country	:	US
Telephone Number	:	718-449-4949
Fax Number	:

Authorized Official
Title or Position	:	TREASURER
Name	:	ISSAM SALAMEH
Credential	:
Telephone Number	:	718-449-4949

Provider Enumeration Date	:	05/20/2020
Last Update Date	:	03/18/2021

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