1821245267 NPI number — MR. BORIS LIDUKHOVER PHARMACIST

Table of content: MR. BORIS LIDUKHOVER PHARMACIST (NPI 1821245267)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821245267 NPI number — MR. BORIS LIDUKHOVER PHARMACIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIDUKHOVER
Provider First Name:
BORIS
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMACIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821245267
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3951 QUEENS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNNYSIDE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11104-3305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-482-0003
Provider Business Mailing Address Fax Number:
718-482-1919

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3951 QUEENS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUNNYSIDE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11104-3305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-482-0003
Provider Business Practice Location Address Fax Number:
718-482-1919
Provider Enumeration Date:
08/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  045584 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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