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Organization
63RD DRIVE RX, INC.
Active
Organization
63RD DRIVE RX, INC.
Active
Other names
InterPharm Rx
Organization subpart
No
Provider details
NPI number
Authorized official
DMITRIY EVTYUSHKIN (OWNER)
(915) 213-8519
Entity
Organization
Contact information
Practice address
9418 ROOSEVELT AVE # 11C11D, JACKSON HEIGHTS, NY 11372-7916
(718) 440-4917
(888) 654-4334
Mailing address
9418 ROOSEVELT AVE # 11C11D, JACKSON HEIGHTS, NY 11372-7916
(718) 440-4917
(888) 654-4334
Taxonomy
Speciality
Code
Description
License number
State
3336L0003X
Long Term Care Pharmacy
Primary
—
NULL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
039844
NY STATE BOARD LICENSE
NY
Enumeration date
09/23/2024
Last updated
09/23/2024
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