Provider Demographics
NPI:1497909824
Name:BB MYRTLE PHARMACY CORP
Entity Type:Organization
Organization Name:BB MYRTLE PHARMACY CORP
Other - Org Name:VITACARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:NATENZON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-720-3710
Mailing Address - Street 1:826 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-2446
Mailing Address - Country:US
Mailing Address - Phone:718-720-3710
Mailing Address - Fax:718-360-9650
Practice Address - Street 1:141 CHARLES AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-1624
Practice Address - Country:US
Practice Address - Phone:718-720-5604
Practice Address - Fax:718-770-7687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-12
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336S0011X, 3336C0004X
NY0293083336L0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2119345OtherPK
NY3056122Medicaid
2119345OtherPK