MEDICARE: CITY ISLAND 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	021389	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2063728	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366439317
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY ISLAND PHARMACY INC

Provider Business Mailing Address
First Line	:	290 CITY ISLAND AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10464-1433
Country	:	US
Telephone Number	:	718-885-3053
Fax Number	:	718-885-2632

Provider Business Practice Location Address
First Line	:	290 CITY ISLAND AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10464-1433
Country	:	US
Telephone Number	:	718-885-3053
Fax Number	:	718-885-2632

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOSEPH MICCARELLI
Credential	:	RPH
Telephone Number	:	718-885-3053

Provider Enumeration Date	:	10/04/2005
Last Update Date	:	09/18/2013

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