Provider Demographics
NPI:1902185366
Name:MYRTLE RX LLC
Entity Type:Organization
Organization Name:MYRTLE RX LLC
Other - Org Name:MYRTLE DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PETE
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTARIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-453-6200
Mailing Address - Street 1:1454 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-5102
Mailing Address - Country:US
Mailing Address - Phone:718-453-6200
Mailing Address - Fax:718-455-3226
Practice Address - Street 1:1454 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-5102
Practice Address - Country:US
Practice Address - Phone:718-453-6200
Practice Address - Fax:718-455-3226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0310193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03361300Medicaid
2133119OtherPK
2133119OtherPK