Provider Demographics
NPI:1477877892
Name:MUMM, JASON A (PHARMD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:A
Last Name:MUMM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6199 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-3846
Mailing Address - Country:US
Mailing Address - Phone:716-648-1475
Mailing Address - Fax:716-648-5894
Practice Address - Street 1:6199 S PARK AVE
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-3846
Practice Address - Country:US
Practice Address - Phone:716-648-1475
Practice Address - Fax:716-648-5894
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-15
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050990183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY050990Medicaid