MEDICARE: 2355 2ND AVE NYS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	333600000X	Pharmacy
2	3336L0003X	Long Term Care Pharmacy
3	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	038283	OTHER	NY	STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	2068954	OTHER		PK

General Provider Information

NPI Number	:	1679628747
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	2355 2ND AVE NYS LLC

Provider Business Mailing Address
First Line	:	2355 2ND AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10035-3107
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2355 2ND AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10035-3107
Country	:	US
Telephone Number	:	212-426-7151
Fax Number	:	646-290-6472

Authorized Official
Title or Position	:	COO
Name	:	SUE ROTTURA
Credential	:
Telephone Number	:	561-323-8987

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	09/26/2023

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