Provider Demographics
NPI:1942221908
Name:5247 BROADWAY DRUGS INC
Entity Type:Organization
Organization Name:5247 BROADWAY DRUGS INC
Other - Org Name:DRUG MART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT,AO
Authorized Official - Prefix:
Authorized Official - First Name:ASHOK
Authorized Official - Middle Name:
Authorized Official - Last Name:BARVALIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-562-6637
Mailing Address - Street 1:5203A BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-7636
Mailing Address - Country:US
Mailing Address - Phone:718-562-6637
Mailing Address - Fax:718-562-5031
Practice Address - Street 1:5203A BROADWAY
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-7636
Practice Address - Country:US
Practice Address - Phone:718-562-6637
Practice Address - Fax:718-562-5031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0229213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2060694OtherPK
NY01639367Medicaid
NY01639367Medicaid