MEDICARE: VAVA PHARMACY INC.

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	025421	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447221023
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VAVA PHARMACY INC.

Provider Business Mailing Address
First Line	:	1403 FOSTER AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-1726
Country	:	US
Telephone Number	:	718-724-1333
Fax Number	:	718-724-2333

Provider Business Practice Location Address
First Line	:	1403 FOSTER AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-1726
Country	:	US
Telephone Number	:	718-724-1333
Fax Number	:	718-724-2333

Authorized Official
Title or Position	:	SECRETARY
Name	:	ARKADIY TAKHALOV
Credential	:
Telephone Number	:	718-724-1333

Provider Enumeration Date	:	01/31/2006
Last Update Date	:	08/19/2014

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