Provider Demographics
NPI:1336837780
Name:CIVA DRUG CORP
Entity Type:Organization
Organization Name:CIVA DRUG CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DIGESH
Authorized Official - Middle Name:C
Authorized Official - Last Name:THAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-273-3314
Mailing Address - Street 1:761 SUFFOLK AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4409
Mailing Address - Country:US
Mailing Address - Phone:631-273-3314
Mailing Address - Fax:631-273-8863
Practice Address - Street 1:761 SUFFOLK AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4409
Practice Address - Country:US
Practice Address - Phone:631-273-3314
Practice Address - Fax:631-273-8863
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CIVA DRUG CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00713240Medicaid