Provider Demographics
NPI:1558344101
Name:AVS PHARMACY/DBA: LEROY PHARMACY
Entity Type:Organization
Organization Name:AVS PHARMACY/DBA: LEROY PHARMACY
Other - Org Name:LEROY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:V
Authorized Official - Last Name:DHADUK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-882-5614
Mailing Address - Street 1:314 EAST 204 ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-4706
Mailing Address - Country:US
Mailing Address - Phone:718-882-5614
Mailing Address - Fax:718-882-6365
Practice Address - Street 1:314 E 204TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-4602
Practice Address - Country:US
Practice Address - Phone:718-882-5614
Practice Address - Fax:718-882-6365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023616333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01871374Medicaid
NY3388584OtherNABP OR NCPDP #
NY1284230001Medicare NSC