Provider Demographics
NPI:1043592926
Name:JETLEY, ANKUR
Entity Type:Individual
Prefix:DR
First Name:ANKUR
Middle Name:
Last Name:JETLEY
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 1:397 ROUTE 46 W
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07004-1967
Mailing Address - Country:US
Mailing Address - Phone:973-568-7830
Mailing Address - Fax:
Practice Address - Street 1:397 ROUTE 46 W
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07004-1967
Practice Address - Country:US
Practice Address - Phone:973-568-7830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02901900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RI02901900OtherNEW JERSEY STATE PHARMACIST LICENSE NUMBER