Provider Demographics
NPI:1790867588
Name:SECOND AVE PHARMACY INC
Entity Type:Organization
Organization Name:SECOND AVE PHARMACY INC
Other - Org Name:SECOND AVE PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER AND SUPERVISING PHCST
Authorized Official - Prefix:
Authorized Official - First Name:VENKATA
Authorized Official - Middle Name:
Authorized Official - Last Name:DONDAPATI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:212-876-8300
Mailing Address - Street 1:249 E 115TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-2130
Mailing Address - Country:US
Mailing Address - Phone:212-876-8300
Mailing Address - Fax:212-876-5280
Practice Address - Street 1:249 E 115TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-2130
Practice Address - Country:US
Practice Address - Phone:212-876-8300
Practice Address - Fax:212-876-5280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0268213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2062983OtherPK
NY02590632Medicaid
NY02590632Medicaid