Provider Demographics
NPI:1457578551
Name:MBG PHARMACY CORP
Entity Type:Organization
Organization Name:MBG PHARMACY CORP
Other - Org Name:IMAGE PRESCIRPTION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:MAKSIM
Authorized Official - Middle Name:
Authorized Official - Last Name:GLEZER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:917-597-7759
Mailing Address - Street 1:119 CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-3917
Mailing Address - Country:US
Mailing Address - Phone:718-686-7343
Mailing Address - Fax:718-686-7492
Practice Address - Street 1:119 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-3917
Practice Address - Country:US
Practice Address - Phone:718-686-7343
Practice Address - Fax:718-626-7492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0256003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02368656Medicaid
2064959OtherPK
4708250001Medicare NSC