Provider Demographics
NPI:1922147974
Name:75 BURNSIDE DRUG AND SURGICAL INC
Entity Type:Organization
Organization Name:75 BURNSIDE DRUG AND SURGICAL INC
Other - Org Name:BURNSIDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:VARGHESE
Authorized Official - Middle Name:
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:BPHARM
Authorized Official - Phone:718-731-8505
Mailing Address - Street 1:75 W BURNSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-4015
Mailing Address - Country:US
Mailing Address - Phone:718-731-8505
Mailing Address - Fax:718-731-8127
Practice Address - Street 1:75 W BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4015
Practice Address - Country:US
Practice Address - Phone:718-731-8505
Practice Address - Fax:718-731-8127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0247713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02082915Medicaid
2061635OtherPK
NY02082915Medicaid
3316901OtherOTHER ID NUMBER