Provider Demographics
NPI:1619704111
Name:POLVANOV, REUVEN
Entity type:Individual
Prefix:DR
First Name:REUVEN
Middle Name:
Last Name:POLVANOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10205 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-2006
Mailing Address - Country:US
Mailing Address - Phone:718-441-4693
Mailing Address - Fax:
Practice Address - Street 1:10205 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-2006
Practice Address - Country:US
Practice Address - Phone:718-441-4693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY071949183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist