=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679370720
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAVANA RX INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2025
-----------------------------------------------------
Last Update Date | 03/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9020 80TH ST
-----------------------------------------------------
City | WOODHAVEN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11421-2465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-233-4040
-----------------------------------------------------
Fax | 347-233-4039
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9020 80TH ST
-----------------------------------------------------
City | WOODHAVEN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11421-2465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-233-4040
-----------------------------------------------------
Fax | 347-233-4039
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | NISSIM SHAVRATOV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 347-233-4040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------