Provider Demographics
NPI:1083938047
Name:ICHTCHENKO, INNA (BS IN PHARMACY)
Entity Type:Individual
Prefix:MRS
First Name:INNA
Middle Name:
Last Name:ICHTCHENKO
Suffix:
Gender:F
Credentials:BS IN PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 HYLAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-1943
Mailing Address - Country:US
Mailing Address - Phone:718-815-2600
Mailing Address - Fax:718-815-2095
Practice Address - Street 1:1250 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-1943
Practice Address - Country:US
Practice Address - Phone:718-815-2600
Practice Address - Fax:718-815-2095
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-19
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045788183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist