Provider Demographics
NPI:1053841312
Name:HEALTHSOURCE PHARMACY IV, LLC
Entity Type:Organization
Organization Name:HEALTHSOURCE PHARMACY IV, LLC
Other - Org Name:HEALTHSOURCE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:NIYAZOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-482-1154
Mailing Address - Street 1:750 COLUMBUS AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025
Mailing Address - Country:US
Mailing Address - Phone:212-932-0200
Mailing Address - Fax:212-932-0202
Practice Address - Street 1:750 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-6464
Practice Address - Country:US
Practice Address - Phone:212-932-0200
Practice Address - Fax:212-932-0202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
NY0354963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2169943OtherPK