Healthcare Provider Details

I. General information

NPI: 1053609354
Provider Name (Legal Business Name): LSH EXPRESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2011
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9914 63RD RD
REGO PARK NY
11374-1940
US

IV. Provider business mailing address

9914 63RD RD
REGO PARK NY
11374-1940
US

V. Phone/Fax

Practice location:
  • Phone: 718-997-7444
  • Fax: 718-997-7445
Mailing address:
  • Phone: 718-997-7444
  • Fax: 718-997-7445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number030750
License Number StateNY

VIII. Authorized Official

Name: RUBEN FATAKHOV
Title or Position: PRESIDENT
Credential:
Phone: 718-997-7444