Provider Demographics
NPI:1689003915
Name:ASARA LLC
Entity Type:Organization
Organization Name:ASARA LLC
Other - Org Name:MERRICK BLVD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RAVI
Authorized Official - Middle Name:
Authorized Official - Last Name:CHITTINEEDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-528-0505
Mailing Address - Street 1:126-13 MERRICK BLVD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434
Mailing Address - Country:US
Mailing Address - Phone:718-528-0505
Mailing Address - Fax:718-528-2151
Practice Address - Street 1:12613 MERRICK BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-3419
Practice Address - Country:US
Practice Address - Phone:718-528-0505
Practice Address - Fax:718-528-2151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-07
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
NY0326373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2145347OtherPK
NY03785251Medicaid