Provider Demographics
NPI:1417270844
Name:TARTAKOVSKIY, LARISA (PHARMD)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:TARTAKOVSKIY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 E 7TH ST
Mailing Address - Street 2:APT#6C
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-6261
Mailing Address - Country:US
Mailing Address - Phone:917-886-1079
Mailing Address - Fax:718-256-7747
Practice Address - Street 1:174 AVENUE O
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-4918
Practice Address - Country:US
Practice Address - Phone:718-256-7757
Practice Address - Fax:718-256-7747
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-12
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048802183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist