Healthcare Provider Details

I. General information

NPI: 1295054286
Provider Name (Legal Business Name): ALEKSEY GABRIYELOV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2010
Last Update Date: 05/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 WOODHAVEN RD
PHILADELPHIA PA
19154-2810
US

IV. Provider business mailing address

414 NEWGATE CT APT. A 2
BENSALEM PA
19020-7769
US

V. Phone/Fax

Practice location:
  • Phone: 215-637-7840
  • Fax: 215-637-2232
Mailing address:
  • Phone: 267-266-9921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP442904
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: