Provider Demographics
NPI:1770276511
Name:ILYASOV, EDUARD
Entity type:Individual
Prefix:
First Name:EDUARD
Middle Name:
Last Name:ILYASOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9740 62ND DR APT 7D
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1324
Mailing Address - Country:US
Mailing Address - Phone:718-200-2852
Mailing Address - Fax:
Practice Address - Street 1:9740 62ND DR APT 7D
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-1324
Practice Address - Country:US
Practice Address - Phone:718-200-2852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-29
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03327500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist