Provider Demographics
NPI:1750565321
Name:DAVYDOVA, OLGA (RPH)
Entity type:Individual
Prefix:MRS
First Name:OLGA
Middle Name:
Last Name:DAVYDOVA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6411 99TH ST APT 311
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2639
Mailing Address - Country:US
Mailing Address - Phone:718-897-0803
Mailing Address - Fax:718-897-0804
Practice Address - Street 1:9511 63RD DR
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2024
Practice Address - Country:US
Practice Address - Phone:718-897-0803
Practice Address - Fax:718-897-0804
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046446183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02850439Medicaid