Healthcare Provider Details

I. General information

NPI: 1033369087
Provider Name (Legal Business Name): INTERBORO PHARMACY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 01/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 NEVINS STREET
BROOKLYN NY
11217
US

IV. Provider business mailing address

75 NEVINS STREET
BROOKLYN NY
11217
US

V. Phone/Fax

Practice location:
  • Phone: 718-858-5500
  • Fax: 718-858-5506
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number029094
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number029094
License Number StateNY

VIII. Authorized Official

Name: MAKSIM GLEZER
Title or Position: PHARMACIST
Credential:
Phone: 917-597-7759