Provider Demographics
NPI:1376826438
Name:KOENIG, MARK (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KOENIG
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 1:15 GALLANT DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NH
Mailing Address - Zip Code:03833-6528
Mailing Address - Country:US
Mailing Address - Phone:602-772-3805
Mailing Address - Fax:
Practice Address - Street 1:3 FREETOWN RD
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:NH
Practice Address - Zip Code:03077-2394
Practice Address - Country:US
Practice Address - Phone:602-895-0657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHR1852183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist