MEDICARE: DR. MARIYA RACKMAN PHARM D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	052782	NY
2	183500000X	Pharmacist	PHA-18365	CO

General Provider Information

NPI Number	:	1063735462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIYA RACKMAN PHARM D

Provider Business Mailing Address
First Line	:	18804 64TH AVE APT 11D
Second Line	:
City	:	FRESH MEADOWS
State	:	NY
Zip	:	11365-3892
Country	:	US
Telephone Number	:	718-454-5028
Fax Number	:

Provider Business Practice Location Address
First Line	:	19718 HILLSIDE AVE
Second Line	:
City	:	HOLLIS
State	:	NY
Zip	:	11423-2127
Country	:	US
Telephone Number	:	718-464-2400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/12/2010
Last Update Date	:	03/12/2010

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