Provider Demographics
NPI:1053605113
Name:GRANDBROOK PHARMACY INC
Entity type:Organization
Organization Name:GRANDBROOK PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/SUP.PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:GHULAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MURTAZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-484-8690
Mailing Address - Street 1:182 LODGE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-2830
Mailing Address - Country:US
Mailing Address - Phone:718-484-8690
Mailing Address - Fax:347-533-8629
Practice Address - Street 1:642 SUTTER AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-4113
Practice Address - Country:US
Practice Address - Phone:718-484-8690
Practice Address - Fax:347-533-8629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-07
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0306403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3344507Medicaid
2130653OtherPK
6542480001Medicare NSC