Provider Demographics
NPI:1033395900
Name:MADZELAN, CARINA CHARLOTTE
Entity Type:Individual
Prefix:
First Name:CARINA
Middle Name:CHARLOTTE
Last Name:MADZELAN
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 1:44 GUNPOWDER DR
Mailing Address - Street 2:UNIT 2093
Mailing Address - City:ATHENS
Mailing Address - State:NY
Mailing Address - Zip Code:12015-4205
Mailing Address - Country:US
Mailing Address - Phone:518-444-4610
Mailing Address - Fax:
Practice Address - Street 1:226 WEST BRIDGE ST
Practice Address - Street 2:
Practice Address - City:CATSKILL
Practice Address - State:NY
Practice Address - Zip Code:12414
Practice Address - Country:US
Practice Address - Phone:518-943-2080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051151-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00533528Medicaid