Provider Demographics
NPI:1922049352
Name:SR PHARMACY INC
Entity Type:Organization
Organization Name:SR PHARMACY INC
Other - Org Name:BROADWAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SRINIVASA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDAVALAPATI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-740-8500
Mailing Address - Street 1:4329 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-2408
Mailing Address - Country:US
Mailing Address - Phone:212-740-8500
Mailing Address - Fax:
Practice Address - Street 1:4329 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-2408
Practice Address - Country:US
Practice Address - Phone:212-740-8500
Practice Address - Fax:212-740-9400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0274733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2066379OtherPK
NY2721093Medicaid