Provider Demographics
NPI:1801260617
Name:BRADDOCK PHARMACY LLC
Entity type:Organization
Organization Name:BRADDOCK PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIPESH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-347-1516
Mailing Address - Street 1:236-01A BRADDOCK AVE.
Mailing Address - Street 2:
Mailing Address - City:BELLEROSE
Mailing Address - State:NY
Mailing Address - Zip Code:11426
Mailing Address - Country:US
Mailing Address - Phone:718-347-1516
Mailing Address - Fax:718-347-1789
Practice Address - Street 1:236-01A BRADDOCK AVE.
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426
Practice Address - Country:US
Practice Address - Phone:718-347-1516
Practice Address - Fax:718-347-1789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032318251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1497185128OtherNPI#
NY7031770001Medicare NSC