Provider Demographics
NPI:1497185128
Name:BRADDOCK PHARMACY LLC
Entity Type:Organization
Organization Name:BRADDOCK PHARMACY LLC
Other - Org Name:BRADDOCK PHARMACY LLC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:KALIOPE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHIONIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-347-1516
Mailing Address - Street 1:236-01A BRADDOCK AVE.
Mailing Address - Street 2:
Mailing Address - City:BELLEROSE
Mailing Address - State:NY
Mailing Address - Zip Code:11426
Mailing Address - Country:US
Mailing Address - Phone:718-347-1516
Mailing Address - Fax:718-347-1789
Practice Address - Street 1:23601A BRADDOCK AVE
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426-1143
Practice Address - Country:US
Practice Address - Phone:718-347-1516
Practice Address - Fax:718-347-1789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-15
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0323183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142918OtherPK
NY04396690Medicaid