MEDICARE: PROSCRIPT PHARMACY MGMT LLC

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	3336M0002X	Mail Order Pharmacy	026894	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3343453	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1831238880
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROSCRIPT PHARMACY MGMT LLC

Provider Business Mailing Address
First Line	:	1441 SOUTH AVE STE 703
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-3784
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1441 SOUTH AVE STE 703
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-3784
Country	:	US
Telephone Number	:	866-646-1780
Fax Number	:	347-897-4660

Authorized Official
Title or Position	:	COO
Name	:	GINA DEBARTOLOME
Credential	:
Telephone Number	:	347-897-4670

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	06/26/2023

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Directions to “PROSCRIPT PHARMACY MGMT LLC ” Practice Location

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