MEDICARE: MS. ELENA NIKOLAEVA

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	056887	NY

General Provider Information

NPI Number	:	1316202500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELENA NIKOLAEVA

Provider Business Mailing Address
First Line	:	1717 77TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11214-1111
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	119 CHURCH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11218-3917
Country	:	US
Telephone Number	:	718-686-7343
Fax Number	:

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

Provider Enumeration Date	:	07/12/2012
Last Update Date	:	07/12/2012

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