Provider Demographics
NPI:1740688068
Name:KATSENELENBOGEN, IGOR
Entity type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:KATSENELENBOGEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 DIX ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:NH
Mailing Address - Zip Code:03222-5129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:89 NH ROUTE 25
Practice Address - Street 2:
Practice Address - City:MEREDITH
Practice Address - State:NH
Practice Address - Zip Code:03253-6314
Practice Address - Country:US
Practice Address - Phone:603-279-4551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHR1680183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist