Provider Demographics
NPI:1619564721
Name:NAVALLIL, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:NAVALLIL
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 1:3 N 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:TAFTVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06380-1407
Mailing Address - Country:US
Mailing Address - Phone:860-383-2013
Mailing Address - Fax:860-383-2135
Practice Address - Street 1:3 N 2ND AVE
Practice Address - Street 2:
Practice Address - City:TAFTVILLE
Practice Address - State:CT
Practice Address - Zip Code:06380-1407
Practice Address - Country:US
Practice Address - Phone:860-383-2013
Practice Address - Fax:860-383-2135
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0014666183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist