Provider Demographics
NPI:1093050445
Name:GOTHAM PHARMACY INC
Entity Type:Organization
Organization Name:GOTHAM PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRULLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-739-2840
Mailing Address - Street 1:2258 3RD AVE
Mailing Address - Street 2:(CORNER OF E 123RD ST AND 3RD AVE)
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035-2208
Mailing Address - Country:US
Mailing Address - Phone:212-289-7800
Mailing Address - Fax:212-289-7806
Practice Address - Street 1:2258 3RD AVE
Practice Address - Street 2:(CORNER OF E 123RD ST AND 3RD AVE)
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-2208
Practice Address - Country:US
Practice Address - Phone:212-289-7800
Practice Address - Fax:212-289-7806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-11
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6759900001Medicare NSC