=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275888463
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHALOM'S DIABETES HEALTH AND WELLNESS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2012
-----------------------------------------------------
Last Update Date | 08/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1490 CONEY ISLAND AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11230-4714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-253-4900
-----------------------------------------------------
Fax | 718-253-4905
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1490 CONEY ISLAND AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11230-4714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-253-4900
-----------------------------------------------------
Fax | 718-253-4905
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST
-----------------------------------------------------
Name | MR. SHALOM RAKHMINOV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-253-4900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 30383
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------