Provider Demographics
NPI:1952648453
Name:DAVID, JAY T (PHARMD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:T
Last Name:DAVID
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3522 N LEAVITT ST
Mailing Address - Street 2:APT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6016
Mailing Address - Country:US
Mailing Address - Phone:630-310-9598
Mailing Address - Fax:
Practice Address - Street 1:850 W IRVING PARK RD
Practice Address - Street 2:OUTPATIENT PHARMACY
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3077
Practice Address - Country:US
Practice Address - Phone:773-975-3235
Practice Address - Fax:773-975-3238
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.293156183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist