Provider Demographics
NPI:1164827630
Name:GORELASHVILI, ILONA
Entity type:Individual
Prefix:
First Name:ILONA
Middle Name:
Last Name:GORELASHVILI
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 1:16711 COLLINS AVE APT 1507
Mailing Address - Street 2:
Mailing Address - City:SUNNY ISLES BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-4293
Mailing Address - Country:US
Mailing Address - Phone:718-844-9817
Mailing Address - Fax:
Practice Address - Street 1:16711 COLLINS AVE APT 1507
Practice Address - Street 2:
Practice Address - City:SUNNY ISLES BEACH
Practice Address - State:FL
Practice Address - Zip Code:33160-4293
Practice Address - Country:US
Practice Address - Phone:718-844-9817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS52647183500000X
NY059678183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist