Provider Demographics
NPI:1790380798
Name:JOSEPH, JAISON
Entity Type:Individual
Prefix:
First Name:JAISON
Middle Name:
Last Name:JOSEPH
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 1:8183 FOXTAIL LOOP
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32526-3242
Mailing Address - Country:US
Mailing Address - Phone:850-316-7604
Mailing Address - Fax:
Practice Address - Street 1:8183 FOXTAIL LOOP
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32526-3242
Practice Address - Country:US
Practice Address - Phone:850-316-7604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS38231183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist