Provider Demographics
NPI:1811370117
Name:KUNJUKUNJU, JACOB VILAYIL
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:VILAYIL
Last Name:KUNJUKUNJU
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 1:6319 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-3641
Mailing Address - Country:US
Mailing Address - Phone:718-429-2140
Mailing Address - Fax:
Practice Address - Street 1:6319 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3641
Practice Address - Country:US
Practice Address - Phone:718-429-2140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-04
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03686700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist