Provider Demographics
NPI:1467869495
Name:MISHKINS PHARMA LLC
Entity Type:Organization
Organization Name:MISHKINS PHARMA LLC
Other - Org Name:MISHKINS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST / MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NAREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ADUSUMELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-926-2801
Mailing Address - Street 1:1714 AMSTERDAM AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-4602
Mailing Address - Country:US
Mailing Address - Phone:212-926-2801
Mailing Address - Fax:212-862-4715
Practice Address - Street 1:1714 AMSTERDAM AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-4602
Practice Address - Country:US
Practice Address - Phone:212-926-2801
Practice Address - Fax:212-862-4715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-22
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0330763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2148254OtherPK
NY04095061Medicaid