Provider Demographics
NPI:1700114790
Name:CHURCH AVE PHARMACY INC
Entity Type:Organization
Organization Name:CHURCH AVE PHARMACY INC
Other - Org Name:CHURCH AVE PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISOR PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:YEFIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BUBIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-941-2200
Mailing Address - Street 1:1810 CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226
Mailing Address - Country:US
Mailing Address - Phone:718-941-2200
Mailing Address - Fax:718-941-2300
Practice Address - Street 1:1810 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226
Practice Address - Country:US
Practice Address - Phone:718-941-2200
Practice Address - Fax:718-941-2300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029857333600000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3176450Medicaid
2123154OtherPK
3363683OtherNCPDP PROVIDER IDENTIFICATION NUMBER