Provider Demographics
NPI:1750482980
Name:ONE SOURCE PHARMACY SERVICES INC.
Entity Type:Organization
Organization Name:ONE SOURCE PHARMACY SERVICES INC.
Other - Org Name:FAIRVIEW PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAYANT
Authorized Official - Middle Name:K
Authorized Official - Last Name:THAKER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:212-567-3384
Mailing Address - Street 1:PO BOX 72
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10602-0072
Mailing Address - Country:US
Mailing Address - Phone:212-567-9186
Mailing Address - Fax:866-486-4959
Practice Address - Street 1:4480 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-2606
Practice Address - Country:US
Practice Address - Phone:212-567-9186
Practice Address - Fax:866-486-4959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024844332B00000X, 3336C0003X, 3336C0004X, 3336H0001X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02105493Medicaid
NY02105493Medicaid