Provider Demographics
NPI:1437410693
Name:MITKO, TED KARL (RPH)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:KARL
Last Name:MITKO
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 1:10 STONEWALL DR
Mailing Address - Street 2:
Mailing Address - City:HOLMES
Mailing Address - State:NY
Mailing Address - Zip Code:12531-5314
Mailing Address - Country:US
Mailing Address - Phone:845-878-8028
Mailing Address - Fax:
Practice Address - Street 1:566 LEONARD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11222-3098
Practice Address - Country:US
Practice Address - Phone:718-389-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044578183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist