Provider Demographics
NPI:1770077604
Name:736 JACKSON PHARMACY CORP
Entity type:Organization
Organization Name:736 JACKSON PHARMACY CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HIREN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:516-850-1656
Mailing Address - Street 1:40 WHEELER AVE
Mailing Address - Street 2:
Mailing Address - City:ALBERTSON
Mailing Address - State:NY
Mailing Address - Zip Code:11507-1610
Mailing Address - Country:US
Mailing Address - Phone:516-850-1656
Mailing Address - Fax:
Practice Address - Street 1:736 E 152ND ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-2203
Practice Address - Country:US
Practice Address - Phone:516-850-1656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy