Provider Demographics
NPI:1922320753
Name:YUSUPOV, YAKOV (PHARMD)
Entity Type:Individual
Prefix:
First Name:YAKOV
Middle Name:
Last Name:YUSUPOV
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 E TREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-5719
Mailing Address - Country:US
Mailing Address - Phone:718-822-5900
Mailing Address - Fax:718-822-5909
Practice Address - Street 1:3131 EAST TREMONT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461
Practice Address - Country:US
Practice Address - Phone:718-822-5900
Practice Address - Fax:718-822-5909
Is Sole Proprietor?:No
Enumeration Date:2010-02-21
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052872183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist