| Organization Name: | 63RD DRIVE PHARMACY CORP |
| NPI Number: | 1023116050 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | SIMON ILIZAROV (PRESIDENT) |
| Mailing Address: | 9305 63rd Dr Rego Park |
| State: | NY US |
| Postal Code: | 113742924 |
| Phone Number: | 7184593370 |
| Fax Number: | 7184592074 |
| NPI Enumeration Date: | 09/21/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 333600000X |
| License Number: | 024647 |
| Healthcare Provider Taxonomy: (Secondary) | X |
| State: | NY |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Pharmacy |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A facility used by pharmacists for the compounding and dispensing of medicinal preparations and other associated professional and administrative services. A pharmacy is a facility whose primary function is to store, prepare and legally dispense prescription drugs under the professional supervision of a licensed pharmacist. It meets any licensing or certification standards set forth by the jurisdiction where it is located. |