Provider Demographics
NPI:1275824898
Name:NILES, JASON W
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:W
Last Name:NILES
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 1:141 SKYLINE TRL
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01011-9696
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:71 PALOMBA DR
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3801
Practice Address - Country:US
Practice Address - Phone:860-749-4184
Practice Address - Fax:860-749-1182
Is Sole Proprietor?:No
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8797183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist