Provider Demographics
NPI:1437978129
Name:IMAGE PRESCRIPTION CENTER LTC
Entity type:Organization
Organization Name:IMAGE PRESCRIPTION CENTER LTC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PIC
Authorized Official - Prefix:
Authorized Official - First Name:MAKSIM
Authorized Official - Middle Name:
Authorized Official - Last Name:GLEZER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-686-7343
Mailing Address - Street 1:119 CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-3917
Mailing Address - Country:US
Mailing Address - Phone:718-686-7343
Mailing Address - Fax:718-686-7492
Practice Address - Street 1:119 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-3917
Practice Address - Country:US
Practice Address - Phone:718-686-7343
Practice Address - Fax:718-686-7492
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MBG PHARMACY CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy