MEDICARE: VYACHESLAV STEVE SHAMALOV RPH

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	183500000X	Pharmacist	050505-1	NY
2	183500000X	Pharmacist	28RI02896100	NJ

General Provider Information

NPI Number	:	1275706798
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VYACHESLAV STEVE SHAMALOV RPH

Provider Business Mailing Address
First Line	:	3741 RIVERDALE AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10463-1807
Country	:	US
Telephone Number	:	718-549-6709
Fax Number	:	718-549-1422

Provider Business Practice Location Address
First Line	:	3741 RIVERDALE AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10463-1807
Country	:	US
Telephone Number	:	718-549-6709
Fax Number	:	718-549-1422

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2008
Last Update Date	:	03/12/2010

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