Provider Demographics
NPI:1710428131
Name:ICON HEALTH SCIENCE
Entity Type:Organization
Organization Name:ICON HEALTH SCIENCE
Other - Org Name:BODY AND PAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:IKECHUKWU (IKAY)
Authorized Official - Middle Name:KANAYO
Authorized Official - Last Name:ENU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-905-4430
Mailing Address - Street 1:40 RICHARDS AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06854-2319
Mailing Address - Country:US
Mailing Address - Phone:800-243-8370
Mailing Address - Fax:888-374-0626
Practice Address - Street 1:40 RICHARDS AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06854-2319
Practice Address - Country:US
Practice Address - Phone:800-243-8370
Practice Address - Fax:888-374-0626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-17
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0067749333600000X, 3336M0002X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy