Provider Demographics
NPI:1689159857
Name:BADALOV, BORIS
Entity Type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:BADALOV
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 1:1103 AVENUE I
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-2907
Mailing Address - Country:US
Mailing Address - Phone:718-252-1589
Mailing Address - Fax:
Practice Address - Street 1:168 HAVEMEYER STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-5410
Practice Address - Country:US
Practice Address - Phone:718-559-5991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY064691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist