Healthcare Provider Details

I. General information

NPI: 1295993855
Provider Name (Legal Business Name): NINA PUCHAEV
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9110 ATLANTIC AVE
OZONE PARK NY
11416-1527
US

IV. Provider business mailing address

7158 163RD ST
FRESH MEADOWS NY
11365-4217
US

V. Phone/Fax

Practice location:
  • Phone: 718-835-7903
  • Fax:
Mailing address:
  • Phone: 718-591-2187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number047667
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: