Provider Demographics
NPI:1376894279
Name:MOLLOY MEDICAL ARTS PHARMA INC
Entity Type:Organization
Organization Name:MOLLOY MEDICAL ARTS PHARMA INC
Other - Org Name:MOLLOY MEDICAL ARTS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GANESH KRISHNACHAND
Authorized Official - Middle Name:
Authorized Official - Last Name:TALASILA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-471-7455
Mailing Address - Street 1:19 BAKER AVE
Mailing Address - Street 2:STE 207
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601
Mailing Address - Country:US
Mailing Address - Phone:845-471-7455
Mailing Address - Fax:845-473-6337
Practice Address - Street 1:19 BAKER AVE STE 207
Practice Address - Street 2:STE 207
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1375
Practice Address - Country:US
Practice Address - Phone:845-471-7455
Practice Address - Fax:845-473-6337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-02
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
NY0316973336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03498666Medicaid
2139794OtherPK
NY031697OtherSTATE BOARD
6758520001Medicare NSC
NY5807384OtherNCPDP
2139794OtherPK