Provider Demographics
NPI:1376098772
Name:PENN PHARMACY INC
Entity Type:Organization
Organization Name:PENN PHARMACY INC
Other - Org Name:PENN PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEKSANDR
Authorized Official - Middle Name:
Authorized Official - Last Name:GULKAROV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-484-4280
Mailing Address - Street 1:1666 BOSTON RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10460
Mailing Address - Country:US
Mailing Address - Phone:718-484-4280
Mailing Address - Fax:718-484-4281
Practice Address - Street 1:1666 BOSTON RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10460-4980
Practice Address - Country:US
Practice Address - Phone:718-484-4280
Practice Address - Fax:718-484-4281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-16
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
NY0349873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2163693OtherPK