Provider Demographics
NPI:1356673818
Name:GAVRILOV, MIKHAIL R (RPH)
Entity Type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:R
Last Name:GAVRILOV
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 1:9952 64TH RD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2646
Mailing Address - Country:US
Mailing Address - Phone:917-325-2150
Mailing Address - Fax:
Practice Address - Street 1:9602 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421-2209
Practice Address - Country:US
Practice Address - Phone:718-805-7000
Practice Address - Fax:718-805-0257
Is Sole Proprietor?:No
Enumeration Date:2010-02-09
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044749183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist