Provider Demographics
NPI:1477852523
Name:GENDRON, MAHOMI (RPH)
Entity Type:Individual
Prefix:
First Name:MAHOMI
Middle Name:
Last Name:GENDRON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 HUBBARD ST
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-3061
Mailing Address - Country:US
Mailing Address - Phone:860-402-1980
Mailing Address - Fax:
Practice Address - Street 1:289 HUBBARD ST
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-3061
Practice Address - Country:US
Practice Address - Phone:860-402-1980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT6274183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist