Healthcare Provider Details

I. General information

NPI: 1760922959
Provider Name (Legal Business Name): COMMUNITY WELLNESS PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2017
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15615 AGUILAR AVE
FLUSHING NY
11367-2727
US

IV. Provider business mailing address

15615 AGUILAR AVE
FLUSHING NY
11367-2727
US

V. Phone/Fax

Practice location:
  • Phone: 718-380-2700
  • Fax: 718-380-2701
Mailing address:
  • Phone: 718-380-2700
  • Fax: 718-380-2701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number034044
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: RAKMIN ILYABAYEV
Title or Position: PRESIDENT
Credential:
Phone: 718-380-2700