Provider Demographics
NPI:1295993855
Name:PUCHAEV, NINA
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:PUCHAEV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7158 163RD ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-4217
Mailing Address - Country:US
Mailing Address - Phone:718-591-2187
Mailing Address - Fax:
Practice Address - Street 1:9110 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11416-1527
Practice Address - Country:US
Practice Address - Phone:718-835-7903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047667183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY047667Medicaid