Provider Demographics
NPI:1942566377
Name:KIKOV, SHALOM SAM
Entity Type:Individual
Prefix:MR
First Name:SHALOM
Middle Name:SAM
Last Name:KIKOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11505 MAYFAIR RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-3481
Mailing Address - Country:US
Mailing Address - Phone:718-757-2869
Mailing Address - Fax:718-261-5505
Practice Address - Street 1:540 FULTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5308
Practice Address - Country:US
Practice Address - Phone:718-757-2869
Practice Address - Fax:718-261-5505
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044335183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist