MEDICARE: HEALTHSOURCE PHARMACY III INC

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	333600000X	Pharmacy	027524	NY
2	3336S0011X	Specialty Pharmacy
3	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3348679	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1023023637
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHSOURCE PHARMACY III INC

Provider Business Mailing Address
First Line	:	235 E 57TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10022-2842
Country	:	US
Telephone Number	:	212-310-0111
Fax Number	:	212-310-0144

Provider Business Practice Location Address
First Line	:	235 E 57TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10022-2842
Country	:	US
Telephone Number	:	212-310-0111
Fax Number	:	212-310-0144

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BORIS NIYAZOV
Credential	:	R.PH, MBA
Telephone Number	:	212-794-8700

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	02/25/2008

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