Provider Demographics
NPI:1962792176
Name:HEALTHSOURCE PHARMACY III B INC
Entity type:Organization
Organization Name:HEALTHSOURCE PHARMACY III B INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:NIYAZOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-310-0111
Mailing Address - Street 1:1000 1ST AVE
Mailing Address - Street 2:AT 55TH STREET
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-4105
Mailing Address - Country:US
Mailing Address - Phone:212-310-0111
Mailing Address - Fax:
Practice Address - Street 1:1000 1ST AVE
Practice Address - Street 2:AT 55TH STREET
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-4105
Practice Address - Country:US
Practice Address - Phone:212-310-0111
Practice Address - Fax:212-310-0144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-10
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0306123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3111442Medicaid
2129913OtherPK