Provider Demographics
NPI:1356965636
Name:BLONDELL RX NY LLC
Entity type:Organization
Organization Name:BLONDELL RX NY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:GARI
Authorized Official - Middle Name:
Authorized Official - Last Name:BASIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-691-3494
Mailing Address - Street 1:1047 SURF AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-2810
Mailing Address - Country:US
Mailing Address - Phone:917-830-2522
Mailing Address - Fax:917-722-0851
Practice Address - Street 1:1642 EASTCHESTER RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2316
Practice Address - Country:US
Practice Address - Phone:347-691-3494
Practice Address - Fax:347-691-3496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-03
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03198827Medicaid