Provider Demographics
NPI:1205158086
Name:IDICULA, JINCY (RPH)
Entity type:Individual
Prefix:
First Name:JINCY
Middle Name:
Last Name:IDICULA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-1937
Mailing Address - Country:US
Mailing Address - Phone:718-698-2136
Mailing Address - Fax:
Practice Address - Street 1:2465 RICHMOND AVE
Practice Address - Street 2:CVS PHARMACY
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314
Practice Address - Country:US
Practice Address - Phone:718-370-0365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053967183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist