Provider Demographics
NPI:1851820740
Name:NEW GRACE PHARMACY LLC
Entity Type:Organization
Organization Name:NEW GRACE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:EDUARD
Authorized Official - Middle Name:
Authorized Official - Last Name:YAKUBOV
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:516-472-7688
Mailing Address - Street 1:10 GRACE AVE
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021
Mailing Address - Country:US
Mailing Address - Phone:516-472-7688
Mailing Address - Fax:516-717-4199
Practice Address - Street 1:10 GRACE AVE
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-2447
Practice Address - Country:US
Practice Address - Phone:516-472-7688
Practice Address - Fax:516-717-4199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-05
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3336C0003X, 3336C0004X, 3336S0011X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05082733Medicaid