Provider Demographics
NPI:1518447861
Name:WOODHAVEN CHEMIST CORP.
Entity Type:Organization
Organization Name:WOODHAVEN CHEMIST CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:MATATOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-441-7111
Mailing Address - Street 1:6939 178TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-3442
Mailing Address - Country:US
Mailing Address - Phone:718-441-7111
Mailing Address - Fax:718-441-8111
Practice Address - Street 1:8622 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421-2005
Practice Address - Country:US
Practice Address - Phone:347-836-3966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-16
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY055993OtherSTATE LICENSE