Provider Demographics
NPI:1659386258
Name:DERIS PHARMACY INC
Entity Type:Organization
Organization Name:DERIS PHARMACY INC
Other - Org Name:BELL BOULEVARD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGINI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-229-2344
Mailing Address - Street 1:4748 BELL BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3334
Mailing Address - Country:US
Mailing Address - Phone:718-229-2344
Mailing Address - Fax:718-717-0004
Practice Address - Street 1:4748 BELL BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3334
Practice Address - Country:US
Practice Address - Phone:718-229-2344
Practice Address - Fax:718-717-0004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
NY0202003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01126154Medicaid
2066412OtherPK
NY01126154Medicaid