Provider Demographics
NPI:1740594985
Name:RAKHMINOV, SHALOM
Entity Type:Individual
Prefix:
First Name:SHALOM
Middle Name:
Last Name:RAKHMINOV
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 1:1106 AVENUE K 1ST FLOOR
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230
Mailing Address - Country:US
Mailing Address - Phone:718-253-4900
Mailing Address - Fax:718-253-4905
Practice Address - Street 1:1106 AVENUE K 1ST FLOOR
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230
Practice Address - Country:US
Practice Address - Phone:718-253-4900
Practice Address - Fax:718-253-4905
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054874183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03297789Medicaid
NY054874Medicaid
NY03297789Medicaid