Provider Demographics
NPI:1083796874
Name:BOYDS OF MADISON
Entity Type:Organization
Organization Name:BOYDS OF MADISON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SRP
Authorized Official - Prefix:
Authorized Official - First Name:IRIWA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAGABAEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-838-6558
Mailing Address - Street 1:968 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-2052
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:968 3RD AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-2052
Practice Address - Country:US
Practice Address - Phone:212-838-6558
Practice Address - Fax:212-838-0229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027375333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3302471OtherOTHER ID NUMBER-COMMERCIAL NUMBER