Provider Demographics
NPI:1457828345
Name:GENESIS PHARMACY
Entity Type:Organization
Organization Name:GENESIS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:BORUKHOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-790-8811
Mailing Address - Street 1:6558 FRESH MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-2012
Mailing Address - Country:US
Mailing Address - Phone:718-353-3555
Mailing Address - Fax:
Practice Address - Street 1:6558 FRESH MEADOW LN
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-2012
Practice Address - Country:US
Practice Address - Phone:718-353-3555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy