Provider Demographics
NPI:1508855990
Name:ETBA PHARMACY INC.
Entity Type:Organization
Organization Name:ETBA PHARMACY INC.
Other - Org Name:BROOK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAMALA
Authorized Official - Middle Name:
Authorized Official - Last Name:IYER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:718-665-2018
Mailing Address - Street 1:530 E 138TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10454-4906
Mailing Address - Country:US
Mailing Address - Phone:718-665-2018
Mailing Address - Fax:718-665-3575
Practice Address - Street 1:530 E 138TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10454-4906
Practice Address - Country:US
Practice Address - Phone:718-665-2018
Practice Address - Fax:718-665-3575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027244333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02646808Medicaid
NY027244OtherBOARD OF PHARMACY
NYBE9459543OtherDEA