MEDICARE: ST THERESA PHARMACY CORP

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	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1619259793
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST THERESA PHARMACY CORP

Provider Business Mailing Address
First Line	:	160 BUSH ST APT 4F
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10453-4306
Country	:	US
Telephone Number	:	646-413-5795
Fax Number	:

Provider Business Practice Location Address
First Line	:	3849 10TH AVENUE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10034
Country	:	US
Telephone Number	:	646-413-5795
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ANTHONY OVALLES
Credential	:
Telephone Number	:	646-413-5795

Provider Enumeration Date	:	09/14/2011
Last Update Date	:	10/15/2011

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