Provider Demographics
NPI:1164753331
Name:LIDSKY, JAY
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:LIDSKY
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 1:731 CEMETERY LN
Mailing Address - Street 2:
Mailing Address - City:ASPEN
Mailing Address - State:CO
Mailing Address - Zip Code:81611-1141
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:731 CEMETERY LN
Practice Address - Street 2:
Practice Address - City:ASPEN
Practice Address - State:CO
Practice Address - Zip Code:81611-1141
Practice Address - Country:US
Practice Address - Phone:970-319-3474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-27
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS17282183500000X
FLPU19521835N1003X
CO18757183500000X, 1835N1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835N1003XPharmacy Service ProvidersPharmacistNutrition Support
No183500000XPharmacy Service ProvidersPharmacist