Provider Demographics
NPI:1740570829
Name:JNR PHARMACY BREWSTER INC
Entity Type:Organization
Organization Name:JNR PHARMACY BREWSTER INC
Other - Org Name:JNR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SRI
Authorized Official - Middle Name:
Authorized Official - Last Name:TALLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-392-8254
Mailing Address - Street 1:2505 CARMEL AVE STE 111
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-1156
Mailing Address - Country:US
Mailing Address - Phone:845-278-8200
Mailing Address - Fax:845-278-4340
Practice Address - Street 1:2505 CARMEL AVE STE 110-111
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-1155
Practice Address - Country:US
Practice Address - Phone:845-278-8200
Practice Address - Fax:845-278-4340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-11
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0307373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3333355Medicaid
2130592OtherPK