Provider Demographics
NPI:1568644003
Name:BOIM, JEREMY ZVI JR
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:ZVI
Last Name:BOIM
Suffix:JR
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 1:768 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-2637
Mailing Address - Country:US
Mailing Address - Phone:516-295-9626
Mailing Address - Fax:
Practice Address - Street 1:260 BROADWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-6229
Practice Address - Country:US
Practice Address - Phone:718-782-3030
Practice Address - Fax:718-782-2626
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045912-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02703762Medicaid