Provider Demographics
NPI:1760665491
Name:BUKHANOV, BORIS (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:BORIS
Middle Name:
Last Name:BUKHANOV
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 FLATBUSH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4518
Mailing Address - Country:US
Mailing Address - Phone:718-951-6869
Mailing Address - Fax:
Practice Address - Street 1:2324 FLATBUSH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4518
Practice Address - Country:US
Practice Address - Phone:718-951-6869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049877183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01764983Medicaid