MEDICARE: EXPRESS DRUG STORE 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	025578	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4858750001	OTHER		MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	3329946	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1750362992
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXPRESS DRUG STORE INC

Provider Business Mailing Address
First Line	:	1408 AVENUE J
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-3702
Country	:	US
Telephone Number	:	718-677-5800
Fax Number	:	718-677-0708

Provider Business Practice Location Address
First Line	:	1408 AVENUE J
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-3702
Country	:	US
Telephone Number	:	718-677-5800
Fax Number	:	718-677-0708

Authorized Official
Title or Position	:	VP
Name	:	DMITRIY PERELMAN
Credential	:	PHARMD
Telephone Number	:	718-677-5800

Provider Enumeration Date	:	11/06/2005
Last Update Date	:	12/15/2010

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Directions to “EXPRESS DRUG STORE INC ” Practice Location

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