Provider Demographics
NPI:1447221023
Name:VAVA PHARMACY INC.
Entity type:Organization
Organization Name:VAVA PHARMACY INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:ARKADIY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAKHALOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-724-1333
Mailing Address - Street 1:1403 FOSTER AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-1726
Mailing Address - Country:US
Mailing Address - Phone:718-724-1333
Mailing Address - Fax:718-724-2333
Practice Address - Street 1:1403 FOSTER AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-1726
Practice Address - Country:US
Practice Address - Phone:718-724-1333
Practice Address - Fax:718-724-2333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0254213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02290673Medicaid
NY02290673Medicaid