Healthcare Provider Details

I. General information

NPI: 1285254367
Provider Name (Legal Business Name): 16TH AVE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2020
Last Update Date: 04/20/2020
Certification Date: 04/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 16TH AVE
BROOKLYN NY
11204-1105
US

IV. Provider business mailing address

4605 16TH AVE
BROOKLYN NY
11204-1105
US

V. Phone/Fax

Practice location:
  • Phone: 718-686-8000
  • Fax: 718-686-8001
Mailing address:
  • Phone: 718-686-8000
  • Fax: 718-686-8001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SOLOMON GULYAMOV
Title or Position: OWNER
Credential:
Phone: 718-686-8000