Provider Demographics
NPI:1396368353
Name:BORUTA, ANDREEA
Entity Type:Individual
Prefix:MRS
First Name:ANDREEA
Middle Name:
Last Name:BORUTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 E 118TH ST APT 10
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035-4447
Mailing Address - Country:US
Mailing Address - Phone:917-403-1418
Mailing Address - Fax:
Practice Address - Street 1:2254 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-2268
Practice Address - Country:US
Practice Address - Phone:212-221-8355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066654183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist