Healthcare Provider Details

I. General information

NPI: 1013272095
Provider Name (Legal Business Name): ALL-SOURCE CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2012
Last Update Date: 09/19/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9109 63RD DR
REGO PARK NY
11374-3849
US

IV. Provider business mailing address

9109 63RD DR
REGO PARK NY
11374-3849
US

V. Phone/Fax

Practice location:
  • Phone: 718-255-6100
  • Fax: 718-255-6104
Mailing address:
  • Phone: 718-255-6100
  • Fax: 718-255-6104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332000000X
TaxonomyMilitary/U.S. Coast Guard Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332100000X
TaxonomyDepartment of Veterans Affairs (VA) Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number031371
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: PETER NYAZOV
Title or Position: PRESIDENT
Credential:
Phone: 718-255-6100