Healthcare Provider Details

I. General information

NPI: 1821003476
Provider Name (Legal Business Name): 18TH AVENUE DRUG STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 03/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8110 18TH AVE
BROOKLYN NY
11214-2201
US

IV. Provider business mailing address

8110 18TH AVE
BROOKLYN NY
11214-2201
US

V. Phone/Fax

Practice location:
  • Phone: 718-232-5566
  • Fax: 718-232-5255
Mailing address:
  • Phone: 718-232-5566
  • Fax: 718-232-5255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number027708
License Number StateNY

VIII. Authorized Official

Name: MARAT BLUSTIN
Title or Position: OWNER/SEC
Credential:
Phone: 917-922-3204