Provider Demographics
NPI:1720269236
Name:YAKUBOV, YEVGENIY
Entity type:Individual
Prefix:
First Name:YEVGENIY
Middle Name:
Last Name:YAKUBOV
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 1:3936 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-3306
Mailing Address - Country:US
Mailing Address - Phone:718-734-2964
Mailing Address - Fax:718-734-2922
Practice Address - Street 1:3936 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-3306
Practice Address - Country:US
Practice Address - Phone:718-734-2964
Practice Address - Fax:718-734-2922
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01704998Medicaid