MEDICARE: INNA GAS 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	046895	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	046895	OTHER	NY	PHARMACY LICENSE

General Provider Information

NPI Number	:	1417139528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	INNA GAS RPH

Provider Business Mailing Address
First Line	:	1419 NEWKIRK AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11226-6521
Country	:	US
Telephone Number	:	718-940-1794
Fax Number	:

Provider Business Practice Location Address
First Line	:	1419 NEWKIRK AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11226-6521
Country	:	US
Telephone Number	:	718-940-1794
Fax Number	:

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

Provider Enumeration Date	:	11/30/2007
Last Update Date	:	03/25/2008

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