Provider Demographics
NPI:1215204318
Name:CARROLLO, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:CARROLLO
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 1:20715 GEMINI TRL
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-2514
Mailing Address - Country:US
Mailing Address - Phone:952-432-5557
Mailing Address - Fax:952-891-3512
Practice Address - Street 1:20715 GEMINI TRL
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044
Practice Address - Country:US
Practice Address - Phone:952-432-5557
Practice Address - Fax:952-891-3512
Is Sole Proprietor?:No
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN117875183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist