Provider Demographics
NPI:1861413833
Name:1225 FULTON AVENUE PHARMACY INC
Entity type:Organization
Organization Name:1225 FULTON AVENUE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-691-3484
Mailing Address - Street 1:1967 WESTCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-4505
Mailing Address - Country:US
Mailing Address - Phone:347-691-3484
Mailing Address - Fax:347-691-3485
Practice Address - Street 1:1967 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462
Practice Address - Country:US
Practice Address - Phone:347-691-3484
Practice Address - Fax:347-691-3485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0274153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2067430OtherPK
NY02723408Medicaid
2067430OtherPK