Provider Demographics
NPI:1053308684
Name:MARTIN DRUGS OF RIVERHEAD,INC
Entity Type:Organization
Organization Name:MARTIN DRUGS OF RIVERHEAD,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRES
Authorized Official - Prefix:MR
Authorized Official - First Name:RAJENDRAPRASAD
Authorized Official - Middle Name:
Authorized Official - Last Name:VENIGALLA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:347-528-8893
Mailing Address - Street 1:849 OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2106
Mailing Address - Country:US
Mailing Address - Phone:631-727-0550
Mailing Address - Fax:631-727-3054
Practice Address - Street 1:849 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2106
Practice Address - Country:US
Practice Address - Phone:631-727-0550
Practice Address - Fax:631-727-3054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019246333600000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00999440Medicaid
NY019246OtherSTATE REGISTRATION
33-43340OtherNCPDP
NY5930670001Medicare NSC