MEDICARE: 16TH AVE 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	:	1285254367
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	16TH AVE PHARMACY LLC

Provider Business Mailing Address
First Line	:	4605 16TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-1105
Country	:	US
Telephone Number	:	718-686-8000
Fax Number	:	718-686-8001

Provider Business Practice Location Address
First Line	:	4605 16TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-1105
Country	:	US
Telephone Number	:	718-686-8000
Fax Number	:	718-686-8001

Authorized Official
Title or Position	:	OWNER
Name	:	SOLOMON GULYAMOV
Credential	:
Telephone Number	:	718-686-8000

Provider Enumeration Date	:	04/20/2020
Last Update Date	:	04/20/2020

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