Provider Demographics
NPI:1023023637
Name:HEALTHSOURCE PHARMACY III INC
Entity Type:Organization
Organization Name:HEALTHSOURCE PHARMACY III INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:NIYAZOV
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, MBA
Authorized Official - Phone:212-794-8700
Mailing Address - Street 1:235 E 57TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-2842
Mailing Address - Country:US
Mailing Address - Phone:212-310-0111
Mailing Address - Fax:212-310-0144
Practice Address - Street 1:235 E 57TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-2842
Practice Address - Country:US
Practice Address - Phone:212-310-0111
Practice Address - Fax:212-310-0144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027524333600000X
3336C0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02748745Medicaid
3348679OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3348679OtherOTHER ID NUMBER-COMMERCIAL NUMBER