Provider Demographics
NPI:1902270838
Name:BOUTIQUE LTC DRUGS INC
Entity Type:Organization
Organization Name:BOUTIQUE LTC DRUGS INC
Other - Org Name:MEDSPLUS PHARMACY SURGICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / OWNER / PIC
Authorized Official - Prefix:
Authorized Official - First Name:CHINTAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:347-232-7688
Mailing Address - Street 1:531 GRAMATAN AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10552
Mailing Address - Country:US
Mailing Address - Phone:914-664-6600
Mailing Address - Fax:914-664-6601
Practice Address - Street 1:531 GRAMATAN AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10552-2103
Practice Address - Country:US
Practice Address - Phone:914-664-6600
Practice Address - Fax:914-664-6601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-16
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0342593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAPPLIEDAWAITINGMedicaid
2155447OtherPK
NY034259Medicaid