Provider Demographics
NPI:1346383403
Name:HEALTHSOURCE PHARMACY II INC
Entity Type:Organization
Organization Name:HEALTHSOURCE PHARMACY II INC
Other - Org Name:HEALTHSOURCE PHARMACY
Other - Org Type:Doing Business As
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:
Authorized Official - Phone:212-481-6600
Mailing Address - Street 1:120 E 34TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-4609
Mailing Address - Country:US
Mailing Address - Phone:212-481-6600
Mailing Address - Fax:212-481-6606
Practice Address - Street 1:120 E 34TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4609
Practice Address - Country:US
Practice Address - Phone:212-481-6600
Practice Address - Fax:212-481-6606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0255013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2064625OtherPK
NY02352789Medicaid
3328083OtherOTHER ID NUMBER-COMMERCIAL NUMBER