Provider Demographics
NPI:1164828125
Name:SOUTHBRONXRXINC
Entity Type:Organization
Organization Name:SOUTHBRONXRXINC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:AJANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOMMAREDDY
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:201-400-2286
Mailing Address - Street 1:1650 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-7606
Mailing Address - Country:US
Mailing Address - Phone:718-538-3385
Mailing Address - Fax:718-538-3384
Practice Address - Street 1:1650 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7606
Practice Address - Country:US
Practice Address - Phone:718-538-3385
Practice Address - Fax:718-538-3384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-18
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0332263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY033226OtherNEW YORK STATE BOARD OF PHARMACY
NY033226OtherNEW YORK STATE BOARD OF PHARMACY