Provider Demographics
NPI:1962488387
Name:MEDLY PHARMACY INC.
Entity Type:Organization
Organization Name:MEDLY PHARMACY INC.
Other - Org Name:BORINQUEN PHARMACY INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SVP PHARMACY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:
Authorized Official - Last Name:FARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-254-9011
Mailing Address - Street 1:31 DEBEVOISE ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-4196
Mailing Address - Country:US
Mailing Address - Phone:718-782-7539
Mailing Address - Fax:718-782-7951
Practice Address - Street 1:31 DEBEVOISE ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-4196
Practice Address - Country:US
Practice Address - Phone:718-782-7539
Practice Address - Fax:718-782-7951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-18
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NY023399333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY023399OtherPHARMACY LICENSE