Provider Demographics
NPI:1578514766
Name:JILLSCOTT CORP
Entity Type:Organization
Organization Name:JILLSCOTT CORP
Other - Org Name:PARK CHEMISTS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:DELLISANTI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:631-667-2484
Mailing Address - Street 1:54 DEER SHORE SQ
Mailing Address - Street 2:
Mailing Address - City:NORTH BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11703-1207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:54 DEER SHORE SQ
Practice Address - Street 2:
Practice Address - City:NORTH BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11703-1207
Practice Address - Country:US
Practice Address - Phone:631-667-2484
Practice Address - Fax:631-667-8887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY154873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3349809OtherOTHER ID NUMBER
NY00461629Medicaid
NY00461629Medicaid