Provider Demographics
NPI:1821314162
Name:RUSA PHARMACY CORP
Entity Type:Organization
Organization Name:RUSA PHARMACY CORP
Other - Org Name:METRO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAGNIA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:BALBUENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-664-8531
Mailing Address - Street 1:342 E 149TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-5635
Mailing Address - Country:US
Mailing Address - Phone:917-664-8531
Mailing Address - Fax:
Practice Address - Street 1:342 E 149TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5635
Practice Address - Country:US
Practice Address - Phone:917-664-8531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-12
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03236555Medicaid
NY03236555Medicaid