Provider Demographics
NPI:1619059409
Name:MIRRA PHARMACY CORP
Entity Type:Organization
Organization Name:MIRRA PHARMACY CORP
Other - Org Name:MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:E
Authorized Official - Last Name:MIRRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-949-7000
Mailing Address - Street 1:82 E POST RD
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10601-5007
Mailing Address - Country:US
Mailing Address - Phone:914-949-7000
Mailing Address - Fax:914-949-3259
Practice Address - Street 1:82 E POST RD
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-5007
Practice Address - Country:US
Practice Address - Phone:914-949-7000
Practice Address - Fax:914-949-3259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0227823336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2060148OtherPK
NY01597671Medicaid
NY01597671Medicaid