MEDICARE: 3340 BROADWAY PHARMACY 2 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	027032	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2063653	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427130210
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	3340 BROADWAY PHARMACY 2 INC

Provider Business Mailing Address
First Line	:	3621 BROADWAY
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10031-2518
Country	:	US
Telephone Number	:	212-926-9800
Fax Number	:	212-926-2228

Provider Business Practice Location Address
First Line	:	3621 BROADWAY
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10031-2518
Country	:	US
Telephone Number	:	212-926-9800
Fax Number	:	212-926-2228

Authorized Official
Title or Position	:	PRESIDENT
Name	:	EDWIN PEREZ
Credential	:
Telephone Number	:	212-926-9800

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	10/27/2014

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