Provider Demographics
NPI:1740465814
Name:BRADHURST SPECIALTY PHARMACY INC
Entity type:Organization
Organization Name:BRADHURST SPECIALTY PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:MELANCON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-449-6939
Mailing Address - Street 1:10050 CROSSTOWN CIR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3348
Mailing Address - Country:US
Mailing Address - Phone:952-979-3680
Mailing Address - Fax:952-352-6698
Practice Address - Street 1:19 BRADHURST AVE
Practice Address - Street 2:SUITE L1
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532-2140
Practice Address - Country:US
Practice Address - Phone:914-345-0070
Practice Address - Fax:914-345-0211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NY028582333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02968394Medicaid
CT1740465814Medicaid
NJ0184781Medicaid
NJ0184781Medicaid