Provider Demographics
NPI:1467495747
Name:GVG PHARMACY INC.
Entity Type:Organization
Organization Name:GVG PHARMACY INC.
Other - Org Name:HOLLIS DRUGS & SURGICALS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNSON
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVADAS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-464-1556
Mailing Address - Street 1:206 08 HOLLIS AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429
Mailing Address - Country:US
Mailing Address - Phone:718-464-1556
Mailing Address - Fax:718-464-1558
Practice Address - Street 1:206 08 HOLLIS AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429
Practice Address - Country:US
Practice Address - Phone:718-464-1556
Practice Address - Fax:718-464-1558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
NY0275383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2067335OtherPK
NY02711420Medicaid
NY02711420Medicaid