Provider Demographics
NPI:1285030460
Name:ISAACSON, GARY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:ISAACSON
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 1:1195 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5970
Mailing Address - Country:US
Mailing Address - Phone:732-703-1895
Mailing Address - Fax:
Practice Address - Street 1:1195 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5970
Practice Address - Country:US
Practice Address - Phone:732-703-1895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02104400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist