Provider Demographics
NPI:1861714164
Name:COFFENBERG, CRAIG JOHN (PHARM D)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:JOHN
Last Name:COFFENBERG
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4623 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:DELANSON
Mailing Address - State:NY
Mailing Address - Zip Code:12053-3930
Mailing Address - Country:US
Mailing Address - Phone:518-505-2071
Mailing Address - Fax:
Practice Address - Street 1:34 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-4120
Practice Address - Country:US
Practice Address - Phone:518-587-3098
Practice Address - Fax:518-587-4925
Is Sole Proprietor?:No
Enumeration Date:2010-02-28
Last Update Date:2010-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053097-1183500000X
MAPH27136183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist