MEDICARE: SJS 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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	014956	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3349897	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174616502
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SJS PHARMACY INC

Provider Business Mailing Address
First Line	:	105-107 E BURNSIDE AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10453-4142
Country	:	US
Telephone Number	:	718-933-1222
Fax Number	:	718-933-1255

Provider Business Practice Location Address
First Line	:	105-107 E BURNSIDE AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10453-4142
Country	:	US
Telephone Number	:	718-933-1222
Fax Number	:	718-933-1255

Authorized Official
Title or Position	:	OWNER
Name	:	EDWARD ILYAICH
Credential	:
Telephone Number	:	718-933-1222

Provider Enumeration Date	:	09/30/2006
Last Update Date	:	10/12/2021

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Directions to “SJS PHARMACY INC ” Practice Location

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