Provider Demographics
NPI:1104207513
Name:ARIAHEALTH
Entity Type:Organization
Organization Name:ARIAHEALTH
Other - Org Name:ARIAHEALTH AT VALUEDRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ILYEVU
Authorized Official - Middle Name:
Authorized Official - Last Name:KALONTAROV
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:718-791-0227
Mailing Address - Street 1:270 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-2554
Mailing Address - Country:US
Mailing Address - Phone:718-791-0227
Mailing Address - Fax:
Practice Address - Street 1:270 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-2554
Practice Address - Country:US
Practice Address - Phone:718-791-0227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-11
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0530423336C0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7428890001Medicare NSC