Provider Demographics
NPI:1679279756
Name:2355 2ND AVE NYS LLC
Entity Type:Organization
Organization Name:2355 2ND AVE NYS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTURRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-323-8987
Mailing Address - Street 1:2355 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035-3107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2355 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-3107
Practice Address - Country:US
Practice Address - Phone:212-426-7151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-01
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06479881Medicaid