Provider Demographics
NPI:1346307311
Name:COLUMBUS & 103RD ST DRUG CORP
Entity Type:Organization
Organization Name:COLUMBUS & 103RD ST DRUG CORP
Other - Org Name:COLUMBUS AVENUE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUBBAB
Authorized Official - Middle Name:
Authorized Official - Last Name:SEHAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-899-8131
Mailing Address - Street 1:916 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-4040
Mailing Address - Country:US
Mailing Address - Phone:212-663-7440
Mailing Address - Fax:212-663-6074
Practice Address - Street 1:916 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-4040
Practice Address - Country:US
Practice Address - Phone:212-663-7440
Practice Address - Fax:212-663-6074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0134093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00269012Medicaid
NY3337791OtherNABP
NY4799460001Medicare NSC