Provider Demographics
NPI:1164605176
Name:TROMBLEY, JASON TODD (RPH)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:TODD
Last Name:TROMBLEY
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 1:3018 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRAL SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:13036-2615
Mailing Address - Country:US
Mailing Address - Phone:315-668-0413
Mailing Address - Fax:315-668-0415
Practice Address - Street 1:3018 EAST AVE
Practice Address - Street 2:
Practice Address - City:CENTRAL SQUARE
Practice Address - State:NY
Practice Address - Zip Code:13036-2615
Practice Address - Country:US
Practice Address - Phone:315-668-0413
Practice Address - Fax:315-668-0415
Is Sole Proprietor?:No
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047501-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02329633Medicaid
NY1316964489OtherNPI