Provider Demographics
NPI:1659972529
Name:GONCHAROV, KIRILL KONSTANTIN
Entity Type:Individual
Prefix:
First Name:KIRILL
Middle Name:KONSTANTIN
Last Name:GONCHAROV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-5722
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75 MAVERICK ST
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-2448
Practice Address - Country:US
Practice Address - Phone:207-596-6389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR12616183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist