MEDICARE: NELLY FUZAYLOV 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	045593-1	NY

General Provider Information

NPI Number	:	1407837222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NELLY FUZAYLOV RPH

Provider Business Mailing Address
First Line	:	114 WHITE AVE
Second Line	:	FT HAMILTON
City	:	BROOKLYN
State	:	NY
Zip	:	11252-9503
Country	:	US
Telephone Number	:	718-630-4268
Fax Number	:

Provider Business Practice Location Address
First Line	:	AINSWORTH US ARMY HEALTH CLINIC PHARMACY
Second Line	:	AINSWORTH US ARMY HEALTH CLINIC BLDG 114
City	:	FORT HAMILTON
State	:	NY
Zip	:	11252-6500
Country	:	US
Telephone Number	:	718-630-4268
Fax Number	:	718-630-4337

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

Provider Enumeration Date	:	11/09/2005
Last Update Date	:	06/25/2010

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