Provider Demographics
NPI:1922320027
Name:KALONTAROV, ILYEVU (RPH)
Entity Type:Individual
Prefix:
First Name:ILYEVU
Middle Name:
Last Name:KALONTAROV
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 1:102-25 67 DRIVE APT 5W
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375
Mailing Address - Country:US
Mailing Address - Phone:631-319-6877
Mailing Address - Fax:
Practice Address - Street 1:10225 67TH DR APT 5W
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-2874
Practice Address - Country:US
Practice Address - Phone:631-319-6877
Practice Address - Fax:888-577-8740
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-17
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053042183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY053042OtherLICENSE NUMBER