Provider Demographics
NPI:1104429877
Name:MIRAKOVA, ELANA
Entity type:Individual
Prefix:
First Name:ELANA
Middle Name:
Last Name:MIRAKOVA
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 1:16406 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-3202
Mailing Address - Country:US
Mailing Address - Phone:718-380-3330
Mailing Address - Fax:
Practice Address - Street 1:16406 69TH AVE
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-3202
Practice Address - Country:US
Practice Address - Phone:718-380-3330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY067121183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist