=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972112993
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BISOMA PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2020
-----------------------------------------------------
Last Update Date | 07/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20520 JAMAICA AVE
-----------------------------------------------------
City | HOLLIS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11423-3021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-217-2091
-----------------------------------------------------
Fax | 718-217-2138
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20520 JAMAICA AVE
-----------------------------------------------------
City | HOLLIS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11423-3021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-217-2091
-----------------------------------------------------
Fax | 718-217-2138
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | YURIY ILYAICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-217-2091
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------