Provider Demographics
NPI:1225342165
Name:GOLD STREET PHARMA INC
Entity Type:Organization
Organization Name:GOLD STREET PHARMA INC
Other - Org Name:NICK'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAVI
Authorized Official - Middle Name:
Authorized Official - Last Name:CHENNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-855-1990
Mailing Address - Street 1:111 GOLD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-1551
Mailing Address - Country:US
Mailing Address - Phone:718-855-1990
Mailing Address - Fax:718-855-1995
Practice Address - Street 1:111 GOLD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-1551
Practice Address - Country:US
Practice Address - Phone:718-855-1990
Practice Address - Fax:718-855-1995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-03
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
NY0304093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2128748OtherPK
NY3261709Medicaid