Healthcare Provider Details

I. General information

NPI: 1699338657
Provider Name (Legal Business Name): KUDEGRA PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 04/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

669 GRAND ST
BROOKLYN NY
11211-4803
US

IV. Provider business mailing address

669 GRAND ST
BROOKLYN NY
11211-4803
US

V. Phone/Fax

Practice location:
  • Phone: 718-916-7597
  • Fax:
Mailing address:
  • Phone: 718-963-1018
  • Fax: 718-963-2635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: MRS. IRYNA KAVA
Title or Position: PRESIDENT
Credential:
Phone: 718-916-7597