Provider Demographics
NPI:1093757874
Name:CLASSIC PHARMACY INC
Entity Type:Organization
Organization Name:CLASSIC PHARMACY INC
Other - Org Name:CLASSIC PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANCALE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-727-0022
Mailing Address - Street 1:1284 CLOVE RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-4301
Mailing Address - Country:US
Mailing Address - Phone:718-727-0022
Mailing Address - Fax:718-727-3316
Practice Address - Street 1:1284 CLOVE RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-4301
Practice Address - Country:US
Practice Address - Phone:718-727-0022
Practice Address - Fax:718-727-3316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0212933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01332365Medicaid
2063241OtherPK
2063241OtherPK