MEDICARE: DRUG STORE INCORPORATED

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	024721	NY

General Provider Information

NPI Number	:	1962543215
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DRUG STORE INCORPORATED

Provider Business Mailing Address
First Line	:	2204 VICTORY BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-6624
Country	:	US
Telephone Number	:	718-982-9438
Fax Number	:	718-698-8978

Provider Business Practice Location Address
First Line	:	2204 VICTORY BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-6624
Country	:	US
Telephone Number	:	718-982-9438
Fax Number	:	718-698-8978

Authorized Official
Title or Position	:	PHARMACIST CO OWNER
Name	:	MR. NICHOLAS AVICOLLI
Credential	:	R.PH
Telephone Number	:	718-982-9438

Provider Enumeration Date	:	02/09/2007
Last Update Date	:	08/22/2020

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