Provider Demographics
NPI:1487911368
Name:JEFFERSON PHARMA LLC
Entity type:Organization
Organization Name:JEFFERSON PHARMA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RAVINDER
Authorized Official - Middle Name:RAO
Authorized Official - Last Name:ANNAMANENI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:929-777-9108
Mailing Address - Street 1:3058 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-4605
Mailing Address - Country:US
Mailing Address - Phone:929-777-9108
Mailing Address - Fax:929-777-9109
Practice Address - Street 1:3058 3RD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-4605
Practice Address - Country:US
Practice Address - Phone:929-777-9108
Practice Address - Fax:929-777-9109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0313673336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136214OtherPK
NY03456062Medicaid
6696770001Medicare NSC