Provider Demographics
NPI:1134521487
Name:SILVER STAR PHARMACY INC
Entity type:Organization
Organization Name:SILVER STAR PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSTYLEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-921-8777
Mailing Address - Street 1:531 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-4801
Mailing Address - Country:US
Mailing Address - Phone:718-921-8777
Mailing Address - Fax:718-921-9777
Practice Address - Street 1:531 E 7TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-4801
Practice Address - Country:US
Practice Address - Phone:718-921-8777
Practice Address - Fax:718-921-9777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-18
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
NY0329253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04052902Medicaid
2148240OtherPK