Provider Demographics
NPI:1316384977
Name:MARBLE HILL PHARMACY CORP.
Entity Type:Organization
Organization Name:MARBLE HILL PHARMACY CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:J
Authorized Official - Last Name:PAGHDAL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-562-5200
Mailing Address - Street 1:5243 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-7636
Mailing Address - Country:US
Mailing Address - Phone:718-562-5200
Mailing Address - Fax:718-562-5300
Practice Address - Street 1:5243 BROADWAY
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-7636
Practice Address - Country:US
Practice Address - Phone:718-562-5200
Practice Address - Fax:718-562-5300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-22
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0319753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03616020Medicaid
NY031975OtherPHARMACY REGISTRATION NUMBER
NY03616020Medicaid