Provider Demographics
NPI:1114594454
Name:KATEHIS, CHARLIE
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:
Last Name:KATEHIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 9TH AVE APT 6B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-5726
Mailing Address - Country:US
Mailing Address - Phone:917-204-4608
Mailing Address - Fax:
Practice Address - Street 1:1440 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-2301
Practice Address - Country:US
Practice Address - Phone:212-221-3844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY067604183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist