Healthcare Provider Details

I. General information

NPI: 1871161307
Provider Name (Legal Business Name): PAVEL ALEKSANDROVICH PRUSAKOV PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2021
Last Update Date: 06/11/2021
Certification Date: 06/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 CHILDRENS DR
COLUMBUS OH
43205-2639
US

IV. Provider business mailing address

700 CHILDRENS DR
COLUMBUS OH
43205-2639
US

V. Phone/Fax

Practice location:
  • Phone: 614-722-6063
  • Fax:
Mailing address:
  • Phone: 614-722-6063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0200X
TaxonomyPediatric Pharmacist
License Number03334836
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: