Provider Demographics
NPI:1801369913
Name:WALD, JILLIAN TAYLOR (PHARMD, RPH)
Entity Type:Individual
Prefix:DR
First Name:JILLIAN
Middle Name:TAYLOR
Last Name:WALD
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 HITCHCOCK AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-1530
Mailing Address - Country:US
Mailing Address - Phone:718-530-4234
Mailing Address - Fax:
Practice Address - Street 1:4055 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-3334
Practice Address - Country:US
Practice Address - Phone:718-966-9285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY064351183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist