Provider Demographics
NPI:1326804485
Name:YEUNG, JACK T
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:T
Last Name:YEUNG
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 1:96 LAUREL BROOK LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-2079
Mailing Address - Country:US
Mailing Address - Phone:646-573-6168
Mailing Address - Fax:
Practice Address - Street 1:96 LAUREL BROOK LN
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-2079
Practice Address - Country:US
Practice Address - Phone:646-573-6168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00103711835P0018X
CTPCT.0010371183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist