=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417612649
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERICA LAYLIEV
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2021
-----------------------------------------------------
Last Update Date | 11/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5917 JUNCTION BLVD
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11373-5188
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-777-2020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10849 68TH RD
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-2956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-794-7688
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 068322
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------