MEDICARE: PRESTIGE CARE 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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	030978	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2132589	OTHER		PK

General Provider Information

NPI Number	:	1679850689
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESTIGE CARE PHARMACY INC

Provider Business Mailing Address
First Line	:	1190 GRAVESEND NECK RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-4208
Country	:	US
Telephone Number	:	718-676-6691
Fax Number	:	718-676-6694

Provider Business Practice Location Address
First Line	:	1190 GRAVESEND NECK RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-4208
Country	:	US
Telephone Number	:	718-676-6691
Fax Number	:	718-676-6694

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DMITRIY SHAPIRO
Credential	:
Telephone Number	:	646-643-3208

Provider Enumeration Date	:	11/05/2011
Last Update Date	:	04/05/2017

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