Provider Demographics
NPI:1437832334
Name:DOMITRZ, NATALY
Entity Type:Individual
Prefix:
First Name:NATALY
Middle Name:
Last Name:DOMITRZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 KRISTIN LN
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06062-2546
Mailing Address - Country:US
Mailing Address - Phone:860-881-1024
Mailing Address - Fax:
Practice Address - Street 1:14 KRISTIN LN
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062-2546
Practice Address - Country:US
Practice Address - Phone:860-881-1024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0016369183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist