Provider Demographics
NPI:1679318125
Name:HEALTHSOURCE PHARMACY INC
Entity type:Organization
Organization Name:HEALTHSOURCE PHARMACY INC
Other - Org Name:
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:212-794-8700
Mailing Address - Street 1:1296 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-5707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1296 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-5707
Practice Address - Country:US
Practice Address - Phone:212-794-8700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEALTHSOURCE PHARMACY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy