Provider Demographics
NPI:1134299548
Name:BRONXDALE PHARMACY INC
Entity type:Organization
Organization Name:BRONXDALE PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-542-0440
Mailing Address - Street 1:1706 WATSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10472-5408
Mailing Address - Country:US
Mailing Address - Phone:718-542-0440
Mailing Address - Fax:718-378-1693
Practice Address - Street 1:1706 WATSON AVENUE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10472-5408
Practice Address - Country:US
Practice Address - Phone:718-542-0440
Practice Address - Fax:718-378-1693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0194223336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1134299548OtherNPI
NY01020731Medicaid
3389992OtherNCPDP
NY01020731Medicaid