Provider Demographics
NPI:1417183518
Name:SOUTHSHORE PHARMACY CORP.
Entity Type:Organization
Organization Name:SOUTHSHORE PHARMACY CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIYA
Authorized Official - Middle Name:N
Authorized Official - Last Name:BRAGINSKY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-948-4848
Mailing Address - Street 1:4020 HYLAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-3331
Mailing Address - Country:US
Mailing Address - Phone:718-948-4848
Mailing Address - Fax:718-948-4899
Practice Address - Street 1:4020 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-3331
Practice Address - Country:US
Practice Address - Phone:718-948-4848
Practice Address - Fax:718-948-4899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-03
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029457333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03132134Medicaid