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NPI Code Detail

MEDICARE: 18TH AVENUE DRUG STORE INC

MEDICARE: 18TH AVENUE 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
13336C0003XCommunity/Retail Pharmacy027708NY

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
13351044OTHERNCPDP PROVIDER IDENTIFICATION NUMBER
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1821003476
Entity Type Code : Organization
Provider Name (Legal Business Name) : 18TH AVENUE DRUG STORE INC
Provider Business Mailing Address
First Line : 8110 18TH AVE
Second Line :
City : BROOKLYN
State : NY
Zip : 11214-2201
Country : US
Telephone Number : 718-232-5566
Fax Number : 718-232-5255
Provider Business Practice Location Address
First Line : 8110 18TH AVE
Second Line :
City : BROOKLYN
State : NY
Zip : 11214-2201
Country : US
Telephone Number : 718-232-5566
Fax Number : 718-232-5255
Authorized Official
Title or Position : OWNER/SEC
Name : MARAT BLUSTIN
Credential :
Telephone Number : 917-922-3204
Provider Enumeration Date : 07/30/2006
Last Update Date : 03/01/2010

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