Provider Demographics
NPI:1467559385
Name:JELUCA PHARMACY CORP
Entity Type:Organization
Organization Name:JELUCA PHARMACY CORP
Other - Org Name:BROADWAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-949-6100
Mailing Address - Street 1:811 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10603-2400
Mailing Address - Country:US
Mailing Address - Phone:914-949-6100
Mailing Address - Fax:914-949-8630
Practice Address - Street 1:811 N BROADWAY
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10603-2400
Practice Address - Country:US
Practice Address - Phone:914-949-6100
Practice Address - Fax:914-949-8630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0262543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02459465Medicaid
3334771OtherNCPDP PROVIDER IDENTIFICATION NUMBER
4945130001Medicare NSC