Provider Demographics
NPI:1851676423
Name:MYTSCHENKO, JOHN (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:MYTSCHENKO
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 1:786 SAINT GEORGES AVE
Mailing Address - Street 2:
Mailing Address - City:RAHWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07065-2627
Mailing Address - Country:US
Mailing Address - Phone:732-499-4582
Mailing Address - Fax:
Practice Address - Street 1:786 SAINT GEORGES AVE
Practice Address - Street 2:
Practice Address - City:RAHWAY
Practice Address - State:NJ
Practice Address - Zip Code:07065-2627
Practice Address - Country:US
Practice Address - Phone:732-499-4582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02218800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist