Provider Demographics
NPI:1073667432
Name:BIG MART PHARMACY INC
Entity Type:Organization
Organization Name:BIG MART PHARMACY INC
Other - Org Name:BIG MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:PERVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-092-3116
Mailing Address - Street 1:2740 3RD AVENUE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455
Mailing Address - Country:US
Mailing Address - Phone:718-292-3116
Mailing Address - Fax:718-292-3142
Practice Address - Street 1:2740 3RD AVENUE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455
Practice Address - Country:US
Practice Address - Phone:718-292-3116
Practice Address - Fax:718-292-3142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3112333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02785817Medicaid