Provider Demographics
NPI:1013272095
Name:ALL-SOURCE CORP
Entity Type:Organization
Organization Name:ALL-SOURCE CORP
Other - Org Name:ALL-SOURCE PHARMACY & SURGICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:NYAZOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-255-6100
Mailing Address - Street 1:9109 63RD DR
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3849
Mailing Address - Country:US
Mailing Address - Phone:718-255-6100
Mailing Address - Fax:718-255-6104
Practice Address - Street 1:9109 63RD DR
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3849
Practice Address - Country:US
Practice Address - Phone:718-255-6100
Practice Address - Fax:718-255-6104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-06
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332000000X, 332100000X, 332B00000X, 332BP3500X, 333600000X, 3336C0004X, 3336M0002X, 3336M0003X, 3336S0011X
NY0313713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332000000XSuppliersMilitary/U.S. Coast Guard Pharmacy
No332100000XSuppliersDepartment of Veterans Affairs (VA) Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135875OtherPK
5805479OtherNCPDP PROVIDER IDENTIFICATION NUMBER