Provider Demographics
NPI:1609183334
Name:TAKHTOVICH, MARY E (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:TAKHTOVICH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 STONEHURST DR
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-2917
Mailing Address - Country:US
Mailing Address - Phone:551-587-8598
Mailing Address - Fax:
Practice Address - Street 1:2760 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-2805
Practice Address - Country:US
Practice Address - Phone:212-678-7893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055066183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist