Provider Demographics
NPI:1487119657
Name:NEKTALOV, NARIK
Entity type:Individual
Prefix:
First Name:NARIK
Middle Name:
Last Name:NEKTALOV
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 1:1398 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-1220
Mailing Address - Country:US
Mailing Address - Phone:718-588-3333
Mailing Address - Fax:718-588-3334
Practice Address - Street 1:1398 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-1220
Practice Address - Country:US
Practice Address - Phone:718-588-3333
Practice Address - Fax:718-588-3334
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
035106OtherSTATE LICENCE
NY04770816Medicaid