Healthcare Provider Details

I. General information

NPI: 1366750911
Provider Name (Legal Business Name): LARISSA REZHETS RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2010
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5313 5TH AVE GROUND FLOOR
BROOKLYN NY
11220-3110
US

IV. Provider business mailing address

165-15 ULIZA MAKSIMA GORKOGO APT 2
TASHKENT TASHKENT
07770
UZ

V. Phone/Fax

Practice location:
  • Phone: 718-567-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number045320
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: