Provider Demographics
NPI:1164603221
Name:HERSCHENHORN, BRIAN (RPH)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:HERSCHENHORN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 HERON PL
Mailing Address - Street 2:
Mailing Address - City:REXFORD
Mailing Address - State:NY
Mailing Address - Zip Code:12148-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 HERON PL
Practice Address - Street 2:
Practice Address - City:REXFORD
Practice Address - State:NY
Practice Address - Zip Code:12148-1380
Practice Address - Country:US
Practice Address - Phone:518-810-9980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049643183500000X
MEPR5031183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01933926Medicaid