Provider Demographics
NPI:1750808796
Name:RAFAILOV, SVETLANA (RPH)
Entity type:Individual
Prefix:
First Name:SVETLANA
Middle Name:
Last Name:RAFAILOV
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:SVETLANA
Other - Middle Name:
Other - Last Name:AVSHALUMOV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:1547 E 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-7105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1547 E 13TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-7105
Practice Address - Country:US
Practice Address - Phone:440-465-7495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-29
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60708851183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist