Provider Demographics
NPI:1649671124
Name:COVIELLO, JESSIE LOREN (CPHT)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:LOREN
Last Name:COVIELLO
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 ROUTE 112
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-1404
Mailing Address - Country:US
Mailing Address - Phone:631-696-4018
Mailing Address - Fax:631-696-4074
Practice Address - Street 1:2850 ROUTE 112
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-1404
Practice Address - Country:US
Practice Address - Phone:631-696-4018
Practice Address - Fax:631-696-4074
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY440101080555806183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician