Healthcare Provider Details

I. General information

NPI: 1285805994
Provider Name (Legal Business Name): MRS. LARISA NOVODVORSKAYA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2008
Last Update Date: 11/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 NEW DORP LN
STATEN ISLAND NY
10306-3005
US

IV. Provider business mailing address

325 NEW DORP LN
STATEN ISLAND NY
10306-3005
US

V. Phone/Fax

Practice location:
  • Phone: 718-351-2400
  • Fax: 718-354-5400
Mailing address:
  • Phone: 718-351-2400
  • Fax: 718-351-5400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number046324-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: