Healthcare Provider Details

I. General information

NPI: 1477804953
Provider Name (Legal Business Name): 39TH STREET PHARMACY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2012
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3902 16TH AVE
BROOKLYN NY
11218-5500
US

IV. Provider business mailing address

3902 16TH AVE
BROOKLYN NY
11218-5500
US

V. Phone/Fax

Practice location:
  • Phone: 718-552-3223
  • Fax: 718-552-2320
Mailing address:
  • Phone: 718-552-2323
  • Fax: 718-552-2320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ASHUR YAKUBOV
Title or Position: PRESIDENT
Credential:
Phone: 718-552-2323