Provider Demographics
NPI:1508878166
Name:JRSTAT PHARMACY INC
Entity Type:Organization
Organization Name:JRSTAT PHARMACY INC
Other - Org Name:JRSTAT PHARMACY INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:XIAO YU
Authorized Official - Middle Name:
Authorized Official - Last Name:LAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-633-2988
Mailing Address - Street 1:7107 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228-1605
Mailing Address - Country:US
Mailing Address - Phone:718-633-2988
Mailing Address - Fax:718-633-6388
Practice Address - Street 1:7107 13TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11228-1605
Practice Address - Country:US
Practice Address - Phone:718-633-2988
Practice Address - Fax:718-633-6388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0287083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02914818Medicaid
2063060OtherPK
NY02914818Medicaid