Provider Demographics
NPI:1114460235
Name:AMAZING COMMUNITY PHARMACY LLC
Entity Type:Organization
Organization Name:AMAZING COMMUNITY PHARMACY LLC
Other - Org Name:AMAZING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SARATHCHANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADUSUMALLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-466-1122
Mailing Address - Street 1:595 E TREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-4727
Mailing Address - Country:US
Mailing Address - Phone:718-466-1122
Mailing Address - Fax:718-466-7747
Practice Address - Street 1:595 E TREMONT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-4727
Practice Address - Country:US
Practice Address - Phone:718-466-1122
Practice Address - Fax:718-466-7747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-21
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0351753336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166959OtherPK
NY04660651Medicaid