MEDICARE: WONDER PHARMACY CORP.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	031133	NY

General Provider Information

NPI Number	:	1003174392
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WONDER PHARMACY CORP.

Provider Business Mailing Address
First Line	:	1665 RALPH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-3317
Country	:	US
Telephone Number	:	718-209-3434
Fax Number	:	718-209-3279

Provider Business Practice Location Address
First Line	:	1665 RALPH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-3317
Country	:	US
Telephone Number	:	718-209-3434
Fax Number	:	718-209-3279

Authorized Official
Title or Position	:	PRESIDENT
Name	:	IRINA OSPOVAT
Credential	:
Telephone Number	:	718-209-3434

Provider Enumeration Date	:	04/25/2012
Last Update Date	:	07/11/2012

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