MEDICARE: IRINA MAKDULIN

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	046403	NY

General Provider Information

NPI Number	:	1235791799
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRINA MAKDULIN

Provider Business Mailing Address
First Line	:	8208 213TH ST
Second Line	:
City	:	QUEENS VILLAGE
State	:	NY
Zip	:	11427-1328
Country	:	US
Telephone Number	:	917-804-8346
Fax Number	:

Provider Business Practice Location Address
First Line	:	8208 213TH ST
Second Line	:
City	:	QUEENS VILLAGE
State	:	NY
Zip	:	11427-1328
Country	:	US
Telephone Number	:	917-804-8346
Fax Number	:

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

Provider Enumeration Date	:	07/05/2019
Last Update Date	:	07/05/2019

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