Provider Demographics
NPI:1912211244
Name:TAKHTAGANOV, ELEONORA
Entity Type:Individual
Prefix:
First Name:ELEONORA
Middle Name:
Last Name:TAKHTAGANOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 CAPICA CT
Mailing Address - Street 2:
Mailing Address - City:LAURENCE HARBOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08879-2911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1447 HWY 35
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NJ
Practice Address - Zip Code:07748-2030
Practice Address - Country:US
Practice Address - Phone:732-671-4234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RT03030500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist