Provider Demographics
NPI:1790876365
Name:3817 BROADWAY PHARMACY
Entity Type:Organization
Organization Name:3817 BROADWAY PHARMACY
Other - Org Name:VIM DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MANICKARAJAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PILLAY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:212-927-0220
Mailing Address - Street 1:3835 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1575
Mailing Address - Country:US
Mailing Address - Phone:212-927-0220
Mailing Address - Fax:
Practice Address - Street 1:3835 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1547
Practice Address - Country:US
Practice Address - Phone:212-927-0220
Practice Address - Fax:212-927-8651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0210133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01266022Medicaid
3318878OtherOTHER ID NUMBER
3986050001Medicare NSC