Provider Demographics
NPI:1376712984
Name:GERSHKOVICH, LEIB (RPH)
Entity Type:Individual
Prefix:MR
First Name:LEIB
Middle Name:
Last Name:GERSHKOVICH
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 1:620 BARNARD AVE
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-2710
Mailing Address - Country:US
Mailing Address - Phone:516-241-5507
Mailing Address - Fax:718-336-8421
Practice Address - Street 1:1651 CONEY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-5849
Practice Address - Country:US
Practice Address - Phone:718-336-8300
Practice Address - Fax:718-336-8421
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043461183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY043461OtherPHARMACIST NY LICENSE #