MEDICARE: ROOSEVELT PHARMACY 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	3336C0003X	Community/Retail Pharmacy		NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861880296
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROOSEVELT PHARMACY INC

Provider Business Mailing Address
First Line	:	13355 ROOSEVELT AVE
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11354-5254
Country	:	US
Telephone Number	:	718-888-1500
Fax Number	:	718-358-3600

Provider Business Practice Location Address
First Line	:	13355 ROOSEVELT AVE
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11354-5254
Country	:	US
Telephone Number	:	718-888-1500
Fax Number	:	718-358-3600

Authorized Official
Title or Position	:	OWNER
Name	:	HENGDA LIU
Credential	:
Telephone Number	:	718-888-1500

Provider Enumeration Date	:	01/08/2015
Last Update Date	:	05/28/2025

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