Provider Demographics
NPI:1790766103
Name:3890 BROADWAY PHARMACY IV, INC.
Entity Type:Organization
Organization Name:3890 BROADWAY PHARMACY IV, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HAYDEE
Authorized Official - Middle Name:
Authorized Official - Last Name:MEREGILDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-568-0975
Mailing Address - Street 1:3898 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032
Mailing Address - Country:US
Mailing Address - Phone:212-568-0975
Mailing Address - Fax:212-568-0976
Practice Address - Street 1:3898 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:212-568-0975
Practice Address - Fax:212-568-0976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027458333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5538980001Medicare NSC
NY5538980001Medicare PIN
NY5538980001Medicare UPIN