Provider Demographics
NPI:1821003476
Name:18TH AVENUE DRUG STORE INC
Entity Type:Organization
Organization Name:18TH AVENUE DRUG STORE INC
Other - Org Name:RX WORLD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/SEC
Authorized Official - Prefix:
Authorized Official - First Name:MARAT
Authorized Official - Middle Name:
Authorized Official - Last Name:BLUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-922-3204
Mailing Address - Street 1:8110 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-2201
Mailing Address - Country:US
Mailing Address - Phone:718-232-5566
Mailing Address - Fax:718-232-5255
Practice Address - Street 1:8110 18TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-2201
Practice Address - Country:US
Practice Address - Phone:718-232-5566
Practice Address - Fax:718-232-5255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0277083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3351044OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NY02673256Medicaid
5680180001Medicare NSC