Provider Demographics
NPI:1568790111
Name:ETHICAL DRUG INC
Entity Type:Organization
Organization Name:ETHICAL DRUG INC
Other - Org Name:SAN NICHOLAS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:RAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-781-4214
Mailing Address - Street 1:1265 SAINT NICHOLAS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-7266
Mailing Address - Country:US
Mailing Address - Phone:212-781-4214
Mailing Address - Fax:212-781-4758
Practice Address - Street 1:1265 SAINT NICHOLAS AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-7266
Practice Address - Country:US
Practice Address - Phone:212-781-4214
Practice Address - Fax:212-281-4758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-19
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0300323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3179691Medicaid
2125491OtherPK