Provider Demographics
NPI:1568056208
Name:ANISCO, JED LESTER BARTOLOME (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JED LESTER
Middle Name:BARTOLOME
Last Name:ANISCO
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 1:7960 RAFAEL RIVERA WAY UNIT 1292
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-5355
Mailing Address - Country:US
Mailing Address - Phone:702-330-7168
Mailing Address - Fax:
Practice Address - Street 1:5801 W CRAIG RD STE 110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-2504
Practice Address - Country:US
Practice Address - Phone:725-251-2253
Practice Address - Fax:725-251-2646
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV19983183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist