Provider Demographics
NPI:1215551593
Name:909 COLUMBUS RX NY LLC
Entity Type:Organization
Organization Name:909 COLUMBUS RX NY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAVTSOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-830-2522
Mailing Address - Street 1:1047 SURF AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-2810
Mailing Address - Country:US
Mailing Address - Phone:917-830-2522
Mailing Address - Fax:917-722-0851
Practice Address - Street 1:909 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-4041
Practice Address - Country:US
Practice Address - Phone:212-222-6388
Practice Address - Fax:646-386-7656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-03
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03048708Medicaid