Provider Demographics
NPI:1790328599
Name:DESTAN, AYDIN (PHARMD)
Entity Type:Individual
Prefix:
First Name:AYDIN
Middle Name:
Last Name:DESTAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 CONCORD DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-3202
Mailing Address - Country:US
Mailing Address - Phone:203-841-9215
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-841-9215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0014816183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist