Provider Demographics
NPI:1790832855
Name:DRUG MART PHARMACY CORP
Entity Type:Organization
Organization Name:DRUG MART PHARMACY CORP
Other - Org Name:DRUG MART PHARMACY CORP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHRM
Authorized Official - Prefix:
Authorized Official - First Name:DOMINICK
Authorized Official - Middle Name:
Authorized Official - Last Name:LETTIERI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-633-4900
Mailing Address - Street 1:4914 NEW UTRECHT AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-3418
Mailing Address - Country:US
Mailing Address - Phone:718-633-4900
Mailing Address - Fax:718-435-0324
Practice Address - Street 1:4914 NEW UTRECHT AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-3418
Practice Address - Country:US
Practice Address - Phone:718-633-4900
Practice Address - Fax:718-435-0324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0200493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01113919Medicaid
2065550OtherPK
NY01113919Medicaid