MEDICARE: MRS. LUBA BALYASNY RPH

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	044099	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	044099	OTHER	NY	PHARMACY LICENSE

General Provider Information

NPI Number	:	1083602650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LUBA BALYASNY RPH

Provider Business Mailing Address
First Line	:	1324 SHEEPSHEAD BAY RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-3920
Country	:	US
Telephone Number	:	917-602-2577
Fax Number	:	718-332-2971

Provider Business Practice Location Address
First Line	:	1324 SHEEPSHEAD BAY RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-3920
Country	:	US
Telephone Number	:	917-602-2577
Fax Number	:	718-332-2971

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

Provider Enumeration Date	:	10/07/2005
Last Update Date	:	07/08/2007

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