Provider Demographics
NPI:1265958649
Name:HERGOTT, PAUL M (RPH)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:M
Last Name:HERGOTT
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 1:445 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-1320
Mailing Address - Country:US
Mailing Address - Phone:203-287-7375
Mailing Address - Fax:203-287-7376
Practice Address - Street 1:445 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-1320
Practice Address - Country:US
Practice Address - Phone:203-287-7375
Practice Address - Fax:203-287-7375
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-17
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7955183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist