Provider Demographics
NPI:1598870370
Name:BUONADONNA'S SHOPRITE LLC
Entity Type:Organization
Organization Name:BUONADONNA'S SHOPRITE LLC
Other - Org Name:BUONADONNA SHOPRITE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUONADONNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-666-7737
Mailing Address - Street 1:64 RT 109
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704
Mailing Address - Country:US
Mailing Address - Phone:631-587-2943
Mailing Address - Fax:631-587-3128
Practice Address - Street 1:50-110 ROUTE 108
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704
Practice Address - Country:US
Practice Address - Phone:631-587-3150
Practice Address - Fax:631-587-3128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0299113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2064645OtherPK
NY02721002Medicaid
NY02721002Medicaid