Provider Demographics
NPI:1962002303
Name:VERISALES, JEMAAL KEENEN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JEMAAL
Middle Name:KEENEN
Last Name:VERISALES
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 1:4770 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1034
Mailing Address - Country:US
Mailing Address - Phone:239-274-2927
Mailing Address - Fax:239-274-2929
Practice Address - Street 1:4770 COLONIAL BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1034
Practice Address - Country:US
Practice Address - Phone:239-274-2927
Practice Address - Fax:239-274-2929
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS57172183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist