Provider Demographics
NPI:1366683021
Name:ELMHURST STAR PHARMACY INC.
Entity Type:Organization
Organization Name:ELMHURST STAR PHARMACY INC.
Other - Org Name:CONCOURSE PHARMCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SATYA
Authorized Official - Middle Name:
Authorized Official - Last Name:DASARI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-229-2200
Mailing Address - Street 1:1850 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-5520
Mailing Address - Country:US
Mailing Address - Phone:718-299-2200
Mailing Address - Fax:718-299-6900
Practice Address - Street 1:1850 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-5520
Practice Address - Country:US
Practice Address - Phone:718-299-2200
Practice Address - Fax:718-299-6200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-10
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0292993336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3360346OtherNCPDP
NY03094066Medicaid
3360346OtherNCPDP