Provider Demographics
NPI:1558340711
Name:MANDRA, JAY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:
Last Name:MANDRA
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 1:20685 CORKSCREW SHORES BLVD
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-9167
Mailing Address - Country:US
Mailing Address - Phone:815-955-3688
Mailing Address - Fax:
Practice Address - Street 1:20685 CORKSCREW SHORES BLVD
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-9167
Practice Address - Country:US
Practice Address - Phone:815-955-3688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-15
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS636331835G0303X
IL051-287659183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric
No183500000XPharmacy Service ProvidersPharmacist