Provider Demographics
NPI:1275706798
Name:SHAMALOV, VYACHESLAV STEVE (RPH)
Entity Type:Individual
Prefix:
First Name:VYACHESLAV
Middle Name:STEVE
Last Name:SHAMALOV
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3741 RIVERDALE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-1807
Mailing Address - Country:US
Mailing Address - Phone:718-549-6709
Mailing Address - Fax:718-549-1422
Practice Address - Street 1:3741 RIVERDALE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-1807
Practice Address - Country:US
Practice Address - Phone:718-549-6709
Practice Address - Fax:718-549-1422
Is Sole Proprietor?:No
Enumeration Date:2008-04-04
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050505-1183500000X
NJ28RI02896100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist