Provider Demographics
NPI:1235497801
Name:MONROE AVENUE PHARMACY INC
Entity Type:Organization
Organization Name:MONROE AVENUE PHARMACY INC
Other - Org Name:RUSHVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING R.PH.
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIGNAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-554-4001
Mailing Address - Street 1:2 SOUTH MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSHVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14544
Mailing Address - Country:US
Mailing Address - Phone:585-554-4001
Mailing Address - Fax:
Practice Address - Street 1:2 SOUTH MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:NY
Practice Address - Zip Code:14544
Practice Address - Country:US
Practice Address - Phone:585-554-4001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-02
Last Update Date:2012-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0312153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5805075OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NY6550530002Medicare NSC