Provider Demographics
NPI:1700928207
Name:3921 9TH AVE PHARMACY INC
Entity Type:Organization
Organization Name:3921 9TH AVE PHARMACY INC
Other - Org Name:PHILLIPS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:OLIVERA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERUNOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-435-7790
Mailing Address - Street 1:3921 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11232-3207
Mailing Address - Country:US
Mailing Address - Phone:718-435-7790
Mailing Address - Fax:718-871-8020
Practice Address - Street 1:3921 9TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11232-3207
Practice Address - Country:US
Practice Address - Phone:718-435-7790
Practice Address - Fax:718-871-8020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01791235Medicaid
NY01791235Medicaid