Healthcare Provider Details

I. General information

NPI: 1902663164
Provider Name (Legal Business Name): ESCRIPT360 QUEENS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6619 FRESH POND RD
RIDGEWOOD NY
11385-3310
US

IV. Provider business mailing address

5 PENNY POND CT
GREENVALE NY
11548-1400
US

V. Phone/Fax

Practice location:
  • Phone: 718-456-6667
  • Fax: 718-456-6668
Mailing address:
  • Phone: 646-633-2170
  • 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: YURIY DAVYDOV
Title or Position: MEMBER
Credential:
Phone: 646-633-2170