MEDICARE: MAPLE AVE 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	027013	NY
2	3336C0003X	Community/Retail Pharmacy	027013	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

General Provider Information

NPI Number	:	1396748810
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAPLE AVE PHARMACY INC

Provider Business Mailing Address
First Line	:	48 BAKERTOWN ROAD
Second Line	:	SUITE 101
City	:	MONROE
State	:	NY
Zip	:	10950
Country	:	US
Telephone Number	:	845-774-1464
Fax Number	:	845-774-1454

Provider Business Practice Location Address
First Line	:	48 BAKERTOWN ROAD
Second Line	:	SUITE 101
City	:	MONROE
State	:	NY
Zip	:	10950
Country	:	US
Telephone Number	:	845-774-1464
Fax Number	:	845-774-1454

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. ISREAL MEILECH WEISSMAN
Credential	:
Telephone Number	:	845-774-1464

Provider Enumeration Date	:	05/30/2005
Last Update Date	:	12/05/2018

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