Organization
HEALTHSOURCE PHARMACY III B INC
Active
Other names
HealthSource Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
BORIS NIYAZOV (PRESIDENT)
(212) 310-0111
Entity
Organization
Contact information
Practice address
1000 1ST AVE, AT 55TH STREET, NEW YORK, NY 10022-4105
(212) 310-0111
(212) 310-0144
Mailing address
1000 1ST AVE, AT 55TH STREET, NEW YORK, NY 10022-4105
(212) 310-0111
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
030612
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2129913
PK
—
05
—
3111442
—
NY
Enumeration date
04/10/2011
Last updated
02/16/2017
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