Provider Demographics
NPI:1821399254
Name:NATENZON, BORIS (RPH)
Entity Type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:NATENZON
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 1:15 W CASTOR PL
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-1150
Mailing Address - Country:US
Mailing Address - Phone:917-734-4662
Mailing Address - Fax:718-360-9650
Practice Address - Street 1:812 FOREST AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-2446
Practice Address - Country:US
Practice Address - Phone:718-720-3700
Practice Address - Fax:718-360-9650
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046718183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist