Provider Demographics
NPI:1285805994
Name:NOVODVORSKAYA, LARISA
Entity type:Individual
Prefix:MRS
First Name:LARISA
Middle Name:
Last Name:NOVODVORSKAYA
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 1:325 NEW DORP LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-3005
Mailing Address - Country:US
Mailing Address - Phone:718-351-2400
Mailing Address - Fax:718-351-5400
Practice Address - Street 1:325 NEW DORP LN
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-3005
Practice Address - Country:US
Practice Address - Phone:718-351-2400
Practice Address - Fax:718-354-5400
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046324-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist