Provider Demographics
NPI:1497025365
Name:LEDERMAN, JAY LEWIS
Entity Type:Individual
Prefix:MR
First Name:JAY
Middle Name:LEWIS
Last Name:LEDERMAN
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 1:26717 WYATT LN
Mailing Address - Street 2:
Mailing Address - City:STEVENSON RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91381-1001
Mailing Address - Country:US
Mailing Address - Phone:661-259-8102
Mailing Address - Fax:661-259-2262
Practice Address - Street 1:3027 RANCHO VISTA BLVD
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-3582
Practice Address - Country:US
Practice Address - Phone:661-265-9741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25886183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist