Provider Demographics
NPI:1073148524
Name:HASABALLA, JACKLEEN (RPH)
Entity Type:Individual
Prefix:
First Name:JACKLEEN
Middle Name:
Last Name:HASABALLA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8422 13TH AVE APT 2F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228-3339
Mailing Address - Country:US
Mailing Address - Phone:631-535-2847
Mailing Address - Fax:
Practice Address - Street 1:7521 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-7419
Practice Address - Country:US
Practice Address - Phone:718-366-2109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065496-01183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist