Provider Demographics
NPI:1467820050
Name:LEVY, ILYA
Entity Type:Individual
Prefix:
First Name:ILYA
Middle Name:
Last Name:LEVY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 WATERS PL
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2720
Mailing Address - Country:US
Mailing Address - Phone:718-450-3313
Mailing Address - Fax:
Practice Address - Street 1:1250 WATERS PL
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2720
Practice Address - Country:US
Practice Address - Phone:718-450-3313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-13
Last Update Date:2015-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060995183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist