Healthcare Provider Details

I. General information

NPI: 1083913917
Provider Name (Legal Business Name): MY RX PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2011
Last Update Date: 04/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17815 UNION TPKE
FRESH MEADOWS NY
11366-1633
US

IV. Provider business mailing address

17815 UNION TPKE
FRESH MEADOWS NY
11366-1633
US

V. Phone/Fax

Practice location:
  • Phone: 718-969-6979
  • Fax: 718-969-4111
Mailing address:
  • Phone: 718-969-6979
  • Fax: 718-969-4111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number030639
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number030639
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number030639
License Number StateNY

VIII. Authorized Official

Name: MR. BORIS KANDOV
Title or Position: OWNER
Credential:
Phone: 718-969-6979