Healthcare Provider Details

I. General information

NPI: 1235935719
Provider Name (Legal Business Name): 119TH ST PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2025
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 E 119TH ST
NEW YORK NY
10035-4069
US

IV. Provider business mailing address

181 E 119TH ST # 10035
NEW YORK NY
10035-4069
US

V. Phone/Fax

Practice location:
  • Phone: 929-348-0044
  • Fax: 347-330-7662
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MIRSAID SHADIEV
Title or Position: PRESIDENT
Credential:
Phone: 929-348-0044