Provider Demographics
NPI:1639144413
Name:LAY, JACK O'NEIL (RPH)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:O'NEIL
Last Name:LAY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 QUAIL DOWN DR
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-4506
Mailing Address - Country:US
Mailing Address - Phone:386-774-8681
Mailing Address - Fax:386-734-3384
Practice Address - Street 1:319 S WOODLAND BLVD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-5853
Practice Address - Country:US
Practice Address - Phone:386-734-3383
Practice Address - Fax:386-734-3384
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS15145183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0146330001Medicare ID - Type Unspecified