Provider Demographics
NPI:1093960056
Name:BOARDWALK RX CORP
Entity Type:Organization
Organization Name:BOARDWALK RX CORP
Other - Org Name:BOARDWALK RX CORP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STANISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:DOLINSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-996-7600
Mailing Address - Street 1:3100 OCEAN PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-8439
Mailing Address - Country:US
Mailing Address - Phone:718-996-7600
Mailing Address - Fax:718-996-7601
Practice Address - Street 1:3100 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-8439
Practice Address - Country:US
Practice Address - Phone:718-996-7600
Practice Address - Fax:718-996-7601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-18
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0292363336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2118523OtherPK
NY03081656Medicaid
NY03081656Medicaid