Provider Demographics
NPI:1164574976
Name:EAST DRIVE PHARMACY, INC.
Entity Type:Organization
Organization Name:EAST DRIVE PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:IRA
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:LIPPELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:212-228-0400
Mailing Address - Street 1:93 AVENUE D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-5338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:93 AVENUE D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10009-5338
Practice Address - Country:US
Practice Address - Phone:212-228-0400
Practice Address - Fax:212-533-0236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018037183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00265687Medicaid
NY3339581OtherNABP