Provider Demographics
NPI:1215097456
Name:VISHNEV PHARMACY CORP
Entity type:Organization
Organization Name:VISHNEV PHARMACY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, SUPERVISING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:LILIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEREBRYAKOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-337-1900
Mailing Address - Street 1:495 BEACH 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-3621
Mailing Address - Country:US
Mailing Address - Phone:718-337-1900
Mailing Address - Fax:718-337-2277
Practice Address - Street 1:495 BEACH 20TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3621
Practice Address - Country:US
Practice Address - Phone:718-337-1900
Practice Address - Fax:718-337-2277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0262563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2063856OtherPK
NY02415910Medicaid
2063856OtherPK