Provider Demographics
NPI:1639255599
Name:GRAND STREET PHARMACEUTICAL LLC
Entity Type:Organization
Organization Name:GRAND STREET PHARMACEUTICAL LLC
Other - Org Name:BUY-RITE PHARMACY IV
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:CEN LIU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-625-9505
Mailing Address - Street 1:215-7 GRAND ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013
Mailing Address - Country:US
Mailing Address - Phone:212-625-9505
Mailing Address - Fax:212-625-9509
Practice Address - Street 1:215-7 GRAND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013
Practice Address - Country:US
Practice Address - Phone:212-625-9505
Practice Address - Fax:212-625-9509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0280303336C0003X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02829894Medicaid
2068665OtherPK
5797790001Medicare NSC