Provider Demographics
NPI:1114388493
Name:SKOLNICK, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:SKOLNICK
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 1:340 N 12TH ST
Mailing Address - Street 2:SUIUTE 110
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-1102
Mailing Address - Country:US
Mailing Address - Phone:844-274-4103
Mailing Address - Fax:267-758-6330
Practice Address - Street 1:340 N 12TH ST
Practice Address - Street 2:SUIUTE 110
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-1102
Practice Address - Country:US
Practice Address - Phone:844-274-4103
Practice Address - Fax:267-758-6330
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP028193L183500000X
NJ28RIO1465000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist