Provider Demographics
NPI:1053426098
Name:PORT JERVIS PHARMACY LLC
Entity type:Organization
Organization Name:PORT JERVIS PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHIRAG
Authorized Official - Middle Name:
Authorized Official - Last Name:MODI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:734-377-2584
Mailing Address - Street 1:15 JERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JERVIS
Mailing Address - State:NY
Mailing Address - Zip Code:12771-2436
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 JERSEY AVE
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-2436
Practice Address - Country:US
Practice Address - Phone:845-856-6681
Practice Address - Fax:845-856-6532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024124333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3374496OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY01879923Medicaid
NY01879923Medicaid
NY1244720001Medicare NSC