MEDICARE: B&T PORT RICHMOND PHARMACY 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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	035842	NY

General Provider Information

NPI Number	:	1184138885
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	B&T PORT RICHMOND PHARMACY INC.

Provider Business Mailing Address
First Line	:	251 PORT RICHMOND AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10302-1704
Country	:	US
Telephone Number	:	718-720-1111
Fax Number	:

Provider Business Practice Location Address
First Line	:	251 PORT RICHMOND AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10302-1704
Country	:	US
Telephone Number	:	718-720-1111
Fax Number	:

Authorized Official
Title or Position	:	SHAREHOLDER
Name	:	MR. ANATOLY GOROKHOVSKY
Credential	:
Telephone Number	:	718-720-1111

Provider Enumeration Date	:	11/17/2017
Last Update Date	:	11/17/2017

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