MEDICARE: OAKLAND GARDENS 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	3336C0003X	Community/Retail Pharmacy	034301	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2158241	OTHER		PK

General Provider Information

NPI Number	:	1720444516
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OAKLAND GARDENS PHARMACY CORP

Provider Business Mailing Address
First Line	:	22417A UNION TPKE
Second Line	:
City	:	OAKLAND GARDENS
State	:	NY
Zip	:	11364-3631
Country	:	US
Telephone Number	:	718-749-5021
Fax Number	:	718-749-5024

Provider Business Practice Location Address
First Line	:	22417A UNION TPKE
Second Line	:
City	:	OAKLAND GARDENS
State	:	NY
Zip	:	11364-3631
Country	:	US
Telephone Number	:	718-749-5021
Fax Number	:	718-749-5024

Authorized Official
Title or Position	:	PRESIDENT
Name	:	YURIY MOSHEYEV
Credential	:
Telephone Number	:	718-749-5021

Provider Enumeration Date	:	01/08/2016
Last Update Date	:	03/08/2016

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