Provider Demographics
NPI:1851634950
Name:PINEBROOK RX INC
Entity Type:Organization
Organization Name:PINEBROOK RX INC
Other - Org Name:PINEBROOK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAVIKUMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:MAMIDELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-992-8182
Mailing Address - Street 1:1183 JEROME AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-3331
Mailing Address - Country:US
Mailing Address - Phone:718-992-8182
Mailing Address - Fax:718-992-8184
Practice Address - Street 1:1183 JEROME AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-3331
Practice Address - Country:US
Practice Address - Phone:718-992-8182
Practice Address - Fax:718-992-8184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031942333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03583382Medicaid
2140759OtherPK