Provider Demographics
NPI:1902847858
Name:731 PHARMACY CORP
Entity Type:Organization
Organization Name:731 PHARMACY CORP
Other - Org Name:IVAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/SUP RPH
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOURDAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-222-4400
Mailing Address - Street 1:691 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-7002
Mailing Address - Country:US
Mailing Address - Phone:212-222-4400
Mailing Address - Fax:212-222-4428
Practice Address - Street 1:691 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-7002
Practice Address - Country:US
Practice Address - Phone:212-222-4400
Practice Address - Fax:212-222-4428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0210823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01281254Medicaid
2067137OtherPK