Provider Demographics
NPI:1477962710
Name:TASSELL, JENNIFER (RPH)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:TASSELL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 CHRISTIAN AVE
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1411
Mailing Address - Country:US
Mailing Address - Phone:317-625-0507
Mailing Address - Fax:
Practice Address - Street 1:464 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2814
Practice Address - Country:US
Practice Address - Phone:631-473-2914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059457183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist