Provider Demographics
NPI:1740873090
Name:NAVARRO-REQUENA, IVAN L (PHARMD)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:L
Last Name:NAVARRO-REQUENA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 ALEXANDER ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-7501
Mailing Address - Country:US
Mailing Address - Phone:860-940-7080
Mailing Address - Fax:
Practice Address - Street 1:81 NORTH ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-4152
Practice Address - Country:US
Practice Address - Phone:860-584-8998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0015356183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist