Provider Demographics
NPI:1427371939
Name:GARDNER, JASON (RPH)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 JAY ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-1569
Mailing Address - Country:US
Mailing Address - Phone:718-246-4100
Mailing Address - Fax:718-246-2417
Practice Address - Street 1:104 JAY ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-1569
Practice Address - Country:US
Practice Address - Phone:718-246-4100
Practice Address - Fax:718-246-2417
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-11
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050651183500000X
SC9464183500000X
LA16298183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist