Provider Demographics
NPI:1407178353
Name:THADATHIL, JIMMY T (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:T
Last Name:THADATHIL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:NONE
Other - Middle Name:
Other - Last Name:NONE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD
Mailing Address - Street 1:7715 250TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLEROSE
Mailing Address - State:NY
Mailing Address - Zip Code:11426-2621
Mailing Address - Country:US
Mailing Address - Phone:917-421-2494
Mailing Address - Fax:
Practice Address - Street 1:7715 250TH ST
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426-2621
Practice Address - Country:US
Practice Address - Phone:917-421-2494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-19
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052031183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYTHAD7777Medicaid