Healthcare Provider Details

I. General information

NPI: 1174390355
Provider Name (Legal Business Name): ERIC ABAYEV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2023
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6743 CENTRAL AVE
GLENDALE NY
11385-6653
US

IV. Provider business mailing address

6929 167TH ST
FRESH MEADOWS NY
11365-3209
US

V. Phone/Fax

Practice location:
  • Phone: 347-445-3797
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number071176
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: