Provider Demographics
NPI:1164643037
Name:FRIEDMAN, JERRY
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:FRIEDMAN
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 1:1631-33 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1514
Mailing Address - Country:US
Mailing Address - Phone:215-496-9595
Mailing Address - Fax:215-790-0900
Practice Address - Street 1:1631-33 SOUTH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-1514
Practice Address - Country:US
Practice Address - Phone:215-496-9595
Practice Address - Fax:215-790-0900
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP415039L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
3922855OtherNDC