Provider Demographics
NPI:1326022922
Name:BROTHERS DRUG CORP
Entity Type:Organization
Organization Name:BROTHERS DRUG CORP
Other - Org Name:VARIETY DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:MANTELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-723-2100
Mailing Address - Street 1:16933 137TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-4517
Mailing Address - Country:US
Mailing Address - Phone:718-723-2100
Mailing Address - Fax:718-978-6427
Practice Address - Street 1:16933 137TH AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-4517
Practice Address - Country:US
Practice Address - Phone:718-723-2100
Practice Address - Fax:718-978-6427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01091221332BC3200X, 332BP3500X, 333600000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01091221Medicaid
NY01091221Medicaid