Provider Demographics
NPI:1184210056
Name:DEBALKO, JONATHAN P
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:P
Last Name:DEBALKO
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 1:322 S HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:MCADOO
Mailing Address - State:PA
Mailing Address - Zip Code:18237-1608
Mailing Address - Country:US
Mailing Address - Phone:570-929-1130
Mailing Address - Fax:570-929-1208
Practice Address - Street 1:322 S HANCOCK ST
Practice Address - Street 2:
Practice Address - City:MCADOO
Practice Address - State:PA
Practice Address - Zip Code:18237-1608
Practice Address - Country:US
Practice Address - Phone:570-929-1130
Practice Address - Fax:570-929-1208
Is Sole Proprietor?:No
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP441786183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist