MEDICARE: BORO PARK PHARMACY CORP.

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	333600000X	Pharmacy
2	3336C0004X	Compounding Pharmacy
3	3336C0003X	Community/Retail Pharmacy	035195	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2175771	OTHER		PK

General Provider Information

NPI Number	:	1538669833
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BORO PARK PHARMACY CORP.

Provider Business Mailing Address
First Line	:	5600 NEW UTRECHT AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-4631
Country	:	US
Telephone Number	:	718-480-0700
Fax Number	:	718-480-7801

Provider Business Practice Location Address
First Line	:	5600 NEW UTRECHT AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-4631
Country	:	US
Telephone Number	:	718-480-0700
Fax Number	:	718-480-7801

Authorized Official
Title or Position	:	SUPERVISING PHARMACIST
Name	:	AKIVA TESSLER
Credential	:
Telephone Number	:	718-982-8505

Provider Enumeration Date	:	02/14/2018
Last Update Date	:	02/14/2018

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Directions to “BORO PARK PHARMACY CORP. ” Practice Location

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