Provider Demographics
NPI:1730476359
Name:BOOTH MEMORIAL AVENUE DRUGS INC
Entity Type:Organization
Organization Name:BOOTH MEMORIAL AVENUE DRUGS INC
Other - Org Name:BOOTH MEMORIAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAHZAD
Authorized Official - Middle Name:
Authorized Official - Last Name:NAWAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-445-9070
Mailing Address - Street 1:13528 BOOTH MEMORIAL AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-5009
Mailing Address - Country:US
Mailing Address - Phone:718-844-5907
Mailing Address - Fax:
Practice Address - Street 1:13528 BOOTH MEMORIAL AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5009
Practice Address - Country:US
Practice Address - Phone:718-844-5907
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-03
Last Update Date:2011-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030752305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY030752OtherSTATE BOARD OF PHARMACY