Provider Demographics
NPI:1841393204
Name:JOLLY, MOHAN J (RPH)
Entity Type:Individual
Prefix:MR
First Name:MOHAN
Middle Name:J
Last Name:JOLLY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
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Mailing Address - Street 1:11 BRANDING IRON LN
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-1638
Mailing Address - Country:US
Mailing Address - Phone:516-676-9111
Mailing Address - Fax:516-676-5162
Practice Address - Street 1:95 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2511
Practice Address - Country:US
Practice Address - Phone:516-676-9111
Practice Address - Fax:516-676-5162
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY030044183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist