MEDICARE: EUGENE BENTSIANOV

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	060148	NY

General Provider Information

NPI Number	:	1780063222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EUGENE BENTSIANOV

Provider Business Mailing Address
First Line	:	2310 KNAPP ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-5924
Country	:	US
Telephone Number	:	718-513-0409
Fax Number	:

Provider Business Practice Location Address
First Line	:	2310 KNAPP ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-5924
Country	:	US
Telephone Number	:	718-513-0409
Fax Number	:

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

Provider Enumeration Date	:	05/28/2015
Last Update Date	:	05/28/2015

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