Provider Demographics
NPI:1972783975
Name:HARRISON, JERRY ANTHONY (RPH)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:ANTHONY
Last Name:HARRISON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-3105
Mailing Address - Country:US
Mailing Address - Phone:631-661-6883
Mailing Address - Fax:
Practice Address - Street 1:532 UNION BLVD
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-3105
Practice Address - Country:US
Practice Address - Phone:631-661-6883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-07
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01484871Medicaid