Provider Demographics
NPI:1831296763
Name:PROHEALTH PHARMACY INC
Entity Type:Organization
Organization Name:PROHEALTH PHARMACY INC
Other - Org Name:PROHEALTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:NOSKOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-684-8300
Mailing Address - Street 1:385 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-4617
Mailing Address - Country:US
Mailing Address - Phone:212-684-8300
Mailing Address - Fax:212-684-3282
Practice Address - Street 1:385 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4617
Practice Address - Country:US
Practice Address - Phone:212-684-8300
Practice Address - Fax:212-684-3282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0245693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01994623Medicaid
NY02247836Medicaid
2059691OtherPK