Provider Demographics
NPI:1508249806
Name:PRXP OF NEW YORK LLC
Entity Type:Organization
Organization Name:PRXP OF NEW YORK LLC
Other - Org Name:BROADWAY FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WAKEFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-477-7803
Mailing Address - Street 1:510 AMSTERDAM AVE
Mailing Address - Street 2:STR1 (SOUTH STORE)
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-3935
Mailing Address - Country:US
Mailing Address - Phone:212-724-1950
Mailing Address - Fax:212-724-1946
Practice Address - Street 1:510 AMSTERDAM AVE
Practice Address - Street 2:STR1
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-3935
Practice Address - Country:US
Practice Address - Phone:212-724-1950
Practice Address - Fax:212-724-1946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-06
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RO00136100333600000X
CTPCN.00030953336C0003X
NY0338383336C0003X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04227134Medicaid
2153018OtherPK
NJ0531928Medicaid
1508249806Medicare NSC