Provider Demographics
NPI:1902557861
Name:CHURBAKOVA, MARIYA
Entity Type:Individual
Prefix:
First Name:MARIYA
Middle Name:
Last Name:CHURBAKOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 BARSTOW RD APT 6H
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-3547
Mailing Address - Country:US
Mailing Address - Phone:347-459-4562
Mailing Address - Fax:
Practice Address - Street 1:3101 DITMARS BLVD
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-2304
Practice Address - Country:US
Practice Address - Phone:718-545-0128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059397183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist