MEDICARE: MEDISOURCE PHARMACY LLC

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
2	3336S0011X	Specialty Pharmacy	028939	NY

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	2070643	OTHER		PK

General Provider Information

NPI Number	:	1215197991
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDISOURCE PHARMACY LLC

Provider Business Mailing Address
First Line	:	720 OLD COUNTRY RD
Second Line	:
City	:	PLAINVIEW
State	:	NY
Zip	:	11803-4929
Country	:	US
Telephone Number	:	516-605-0080
Fax Number	:	516-605-0077

Provider Business Practice Location Address
First Line	:	720 OLD COUNTRY RD
Second Line	:
City	:	PLAINVIEW
State	:	NY
Zip	:	11803-4929
Country	:	US
Telephone Number	:	516-605-0080
Fax Number	:	516-605-0077

Authorized Official
Title or Position	:	OWNER
Name	:	ROZA DAVIDOV
Credential	:
Telephone Number	:	516-615-2974

Provider Enumeration Date	:	06/16/2008
Last Update Date	:	01/27/2026

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Directions to “MEDISOURCE PHARMACY LLC ” Practice Location

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