MEDICARE: CEDRA PHARMACY BROADWAY LLC

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	035007	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2165971	OTHER		PK

General Provider Information

NPI Number	:	1396297024
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CEDRA PHARMACY BROADWAY LLC

Provider Business Mailing Address
First Line	:	724 ELTON AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10455-1687
Country	:	US
Telephone Number	:	917-836-8886
Fax Number	:	212-877-5002

Provider Business Practice Location Address
First Line	:	2268 BROADWAY
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10024-5403
Country	:	US
Telephone Number	:	212-877-5000
Fax Number	:	212-877-5002

Authorized Official
Title or Position	:	CEO
Name	:	MAZEN KARNABY
Credential	:
Telephone Number	:	917-836-8886

Provider Enumeration Date	:	10/28/2016
Last Update Date	:	10/25/2023

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