Provider Demographics
NPI:1033309547
Name:BOULEVARD PHARMACY CORP
Entity Type:Organization
Organization Name:BOULEVARD PHARMACY CORP
Other - Org Name:GARDEN CITY FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PASQUALE
Authorized Official - Middle Name:
Authorized Official - Last Name:MINUTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-505-7979
Mailing Address - Street 1:10 NASSAU BLVD SO
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530
Mailing Address - Country:US
Mailing Address - Phone:516-505-7979
Mailing Address - Fax:516-505-7981
Practice Address - Street 1:10 NASSAU BLVD SO
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530
Practice Address - Country:US
Practice Address - Phone:516-505-7979
Practice Address - Fax:516-505-7981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NY0286123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
3355737OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NY03069647Medicaid