Provider Demographics
NPI:1427237932
Name:HENDERSON, CARL D
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:D
Last Name:HENDERSON
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 1:27 ROUND LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BALLSTON LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12019-1129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27 ROUND LAKE RD
Practice Address - Street 2:
Practice Address - City:BALLSTON LAKE
Practice Address - State:NY
Practice Address - Zip Code:12019-1129
Practice Address - Country:US
Practice Address - Phone:518-899-2986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034122183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist