Provider Demographics
NPI:1578686374
Name:KOCH, NELSON V (RPH)
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:V
Last Name:KOCH
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 1:2280 N OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-2911
Mailing Address - Country:US
Mailing Address - Phone:631-732-1960
Mailing Address - Fax:631-732-6876
Practice Address - Street 1:2280 N OCEAN AVE
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-2911
Practice Address - Country:US
Practice Address - Phone:631-732-1960
Practice Address - Fax:631-732-6876
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027716183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist