Provider Demographics
NPI:1326135294
Name:SHREE GANESH PHARMACY
Entity Type:Organization
Organization Name:SHREE GANESH PHARMACY
Other - Org Name:SPAN AM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARM/CLERK
Authorized Official - Prefix:
Authorized Official - First Name:MANISH
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-401-6778
Mailing Address - Street 1:2810 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2810 3RD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455
Practice Address - Country:US
Practice Address - Phone:718-401-6778
Practice Address - Fax:718-993-1497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026777333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3325049OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY02544214Medicaid