Provider Demographics
NPI:1275674376
Name:BRISELY PHARMACY INC
Entity Type:Organization
Organization Name:BRISELY PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:MENDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:212-781-6314
Mailing Address - Street 1:4229 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-3707
Mailing Address - Country:US
Mailing Address - Phone:212-781-6314
Mailing Address - Fax:212-795-7343
Practice Address - Street 1:4229 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-3707
Practice Address - Country:US
Practice Address - Phone:212-781-6314
Practice Address - Fax:212-795-7343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0187993336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00914663Medicaid
NY3385158OtherPHARMACY
NY1322350001Medicare NSC