MEDICARE: ETBA 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	027244	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
2	027244	OTHER	NY	BOARD OF PHARMACY

General Provider Information

NPI Number	:	1508855990
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ETBA PHARMACY INC.

Provider Business Mailing Address
First Line	:	530 E 138TH ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10454-4906
Country	:	US
Telephone Number	:	718-665-2018
Fax Number	:	718-665-3575

Provider Business Practice Location Address
First Line	:	530 E 138TH ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10454-4906
Country	:	US
Telephone Number	:	718-665-2018
Fax Number	:	718-665-3575

Authorized Official
Title or Position	:	PHARMACIST/MANAGER
Name	:	MRS. KAMALA IYER
Credential	:	PHARMACIST
Telephone Number	:	718-665-2018

Provider Enumeration Date	:	10/18/2005
Last Update Date	:	03/07/2023

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