Provider Demographics
NPI:1376725093
Name:KORETSKY, CHRISTOPHER JEFFREY (RPH)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JEFFREY
Last Name:KORETSKY
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 1:430 JERUSALEM AVE
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-5504
Mailing Address - Country:US
Mailing Address - Phone:516-937-7500
Mailing Address - Fax:516-937-7500
Practice Address - Street 1:430 JERUSALEM AVE
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-5504
Practice Address - Country:US
Practice Address - Phone:516-937-7500
Practice Address - Fax:516-937-7500
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030869183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01877123Medicaid