Provider Demographics
NPI:1831416536
Name:PGU PHARMACY INC
Entity type:Organization
Organization Name:PGU PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHARMACIST / MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SRINIVASULU
Authorized Official - Middle Name:
Authorized Official - Last Name:THOTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-597-7999
Mailing Address - Street 1:1229 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-3515
Mailing Address - Country:US
Mailing Address - Phone:347-597-7999
Mailing Address - Fax:347-597-7405
Practice Address - Street 1:1229 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-3515
Practice Address - Country:US
Practice Address - Phone:347-597-7999
Practice Address - Fax:347-597-7405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-21
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0337973336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04240608Medicaid
2154282OtherPK
NY04240608Medicaid
7484960001Medicare NSC
2154282OtherPK