Provider Demographics
NPI:1851576805
Name:KAPUSTINA, LARISA (RPH)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:KAPUSTINA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 GRAVESEND NECK RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229
Mailing Address - Country:US
Mailing Address - Phone:718-627-7070
Mailing Address - Fax:718-627-7374
Practice Address - Street 1:1311 GRAVESEND NECK RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4328
Practice Address - Country:US
Practice Address - Phone:718-627-7070
Practice Address - Fax:718-627-7374
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044087183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist