MEDICARE: 119TH ST 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

General Provider Information

NPI Number	:	1235935719
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	119TH ST PHARMACY LLC

Provider Business Mailing Address
First Line	:	181 E 119TH ST # 10035
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10035-4069
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	181 E 119TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10035-4069
Country	:	US
Telephone Number	:	929-348-0044
Fax Number	:	347-330-7662

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MIRSAID SHADIEV
Credential	:
Telephone Number	:	929-348-0044

Provider Enumeration Date	:	02/24/2025
Last Update Date	:	07/15/2025

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