Provider Demographics
NPI:1073793717
Name:SACKS, JAY L (RPH)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:L
Last Name:SACKS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:NY
Mailing Address - Zip Code:13815-1332
Mailing Address - Country:US
Mailing Address - Phone:607-334-2265
Mailing Address - Fax:607-336-7260
Practice Address - Street 1:82 N BROAD ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:NY
Practice Address - Zip Code:13815-1332
Practice Address - Country:US
Practice Address - Phone:607-334-2265
Practice Address - Fax:607-336-7260
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027145183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00578423Medicaid