Provider Demographics
NPI:1932225620
Name:GLEN COVE PHARM LLC
Entity Type:Organization
Organization Name:GLEN COVE PHARM LLC
Other - Org Name:GLEN COVE CHEMISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:516-676-9111
Mailing Address - Street 1:20 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2106
Mailing Address - Country:US
Mailing Address - Phone:516-676-9111
Mailing Address - Fax:516-676-5162
Practice Address - Street 1:20 FOREST AVE
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2106
Practice Address - Country:US
Practice Address - Phone:516-676-9111
Practice Address - Fax:516-676-5162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
NY0252203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02205301Medicaid
2063681OtherPK
4389830001Medicare NSC