Provider Demographics
NPI:1346331998
Name:MALCOLM PHARMACY INC
Entity Type:Organization
Organization Name:MALCOLM PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MALLIKARJUNA
Authorized Official - Middle Name:REDDY
Authorized Official - Last Name:BOMMAREDDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-722-1550
Mailing Address - Street 1:160 LENOX AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-1319
Mailing Address - Country:US
Mailing Address - Phone:212-722-1550
Mailing Address - Fax:212-722-4461
Practice Address - Street 1:160 LENOX AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-1319
Practice Address - Country:US
Practice Address - Phone:212-722-1550
Practice Address - Fax:212-722-4461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0250963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02188856Medicaid
4282380001Medicare NSC