=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316761679
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VALUE MART PHARMACY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2024
-----------------------------------------------------
Last Update Date | 11/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19111 JAMAICA AVE
-----------------------------------------------------
City | HOLLIS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11423-2527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-971-6643
-----------------------------------------------------
Fax | 718-691-4121
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19111 JAMAICA AVE
-----------------------------------------------------
City | HOLLIS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11423-2527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-971-6643
-----------------------------------------------------
Fax | 718-691-4121
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ILINA SHAKHMUROVA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-971-6643
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------