Provider Demographics
NPI:1033108311
Name:STARRETT CITY PHARMACY, LLC
Entity Type:Organization
Organization Name:STARRETT CITY PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:VAYSBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-257-8777
Mailing Address - Street 1:1110 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE # 12
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-9061
Mailing Address - Country:US
Mailing Address - Phone:718-257-8777
Mailing Address - Fax:718-257-8884
Practice Address - Street 1:1110 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-9061
Practice Address - Country:US
Practice Address - Phone:718-257-8777
Practice Address - Fax:718-257-8884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025076333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3322308OtherNCDP
NY02168005Medicaid
NY4234610001Medicare ID - Type Unspecified