Provider Demographics
NPI:1912163536
Name:ROSE DRUG STORE INC
Entity Type:Organization
Organization Name:ROSE DRUG STORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OSAHON
Authorized Official - Middle Name:EVANS
Authorized Official - Last Name:IMAFIDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-812-9654
Mailing Address - Street 1:262 E BURNSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-3724
Mailing Address - Country:US
Mailing Address - Phone:171-829-1470
Mailing Address - Fax:
Practice Address - Street 1:262 E BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-3724
Practice Address - Country:US
Practice Address - Phone:171-829-1470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0290023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY029002OtherBOARD OF PHARMACY
NY3358531OtherNCPDP
NY03044066Medicaid
NY03044066Medicaid
NY6139730001Medicare NSC