Provider Demographics
NPI:1679805949
Name:GHOLIAN, JACOB (DR)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:GHOLIAN
Suffix:
Gender:M
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3406 AVENUE P
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-3441
Mailing Address - Country:US
Mailing Address - Phone:347-733-4422
Mailing Address - Fax:
Practice Address - Street 1:1450 ROCKAWAY PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-2602
Practice Address - Country:US
Practice Address - Phone:718-272-2504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054214-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist