Provider Demographics
NPI:1669741831
Name:JOSEPH, JIBY
Entity type:Individual
Prefix:MR
First Name:JIBY
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 N US HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-3195
Mailing Address - Country:US
Mailing Address - Phone:352-753-3257
Mailing Address - Fax:352-753-7258
Practice Address - Street 1:890 N US HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-3195
Practice Address - Country:US
Practice Address - Phone:352-753-3257
Practice Address - Fax:352-753-7258
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-18
Last Update Date:2011-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS45454183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist