Provider Demographics
NPI:1972536456
Name:133RD STREET PHARMACY INC
Entity Type:Organization
Organization Name:133RD STREET PHARMACY INC
Other - Org Name:133RD ST PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUP PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:BHARGAV
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:212-491-4911
Mailing Address - Street 1:1473 AMSTERDAM AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-7472
Mailing Address - Country:US
Mailing Address - Phone:212-491-4911
Mailing Address - Fax:212-491-4916
Practice Address - Street 1:1473 AMSTERDAM AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-7472
Practice Address - Country:US
Practice Address - Phone:212-491-4911
Practice Address - Fax:212-491-4916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0275643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02723279Medicaid
2067350OtherPK
NY02723279Medicaid