Provider Demographics
NPI:1942847041
Name:BOULEVARD 9229 LLC
Entity Type:Organization
Organization Name:BOULEVARD 9229 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ISHBAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUKUROV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-639-1663
Mailing Address - Street 1:9229 QUEENS BLVD STE 1I
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1072
Mailing Address - Country:US
Mailing Address - Phone:347-639-1663
Mailing Address - Fax:347-639-0046
Practice Address - Street 1:9229 QUEENS BLVD STE 1I
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-1072
Practice Address - Country:US
Practice Address - Phone:347-639-1663
Practice Address - Fax:347-639-0046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-08
Last Update Date:2019-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy