Provider Demographics
NPI:1033543905
Name:FATAKHOV, IGOR (PHARM D)
Entity Type:Individual
Prefix:MR
First Name:IGOR
Middle Name:
Last Name:FATAKHOV
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9924 65TH RD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3655
Mailing Address - Country:US
Mailing Address - Phone:917-815-8345
Mailing Address - Fax:
Practice Address - Street 1:9924 65TH RD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3655
Practice Address - Country:US
Practice Address - Phone:917-815-8345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058401183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist