Provider Demographics
NPI:1417116021
Name:KANDOV, LEANA S
Entity Type:Individual
Prefix:
First Name:LEANA
Middle Name:S
Last Name:KANDOV
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 1:10240 67TH RD
Mailing Address - Street 2:APT 4G
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-2663
Mailing Address - Country:US
Mailing Address - Phone:646-750-4489
Mailing Address - Fax:
Practice Address - Street 1:3224 STEINWAY ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-4006
Practice Address - Country:US
Practice Address - Phone:718-204-7867
Practice Address - Fax:718-204-5936
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047867183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0514203157Medicaid