Provider Demographics
NPI:1063163889
Name:LASTOVKINA, TATIANA
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:LASTOVKINA
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 1:215 ALEXANDER AVE
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07731-8681
Mailing Address - Country:US
Mailing Address - Phone:347-834-6643
Mailing Address - Fax:
Practice Address - Street 1:40 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876-2203
Practice Address - Country:US
Practice Address - Phone:908-725-0585
Practice Address - Fax:908-725-0587
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04213500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ00000OtherN/A