Provider Demographics
NPI:1770752354
Name:GUBERMAN, JACOB (RPH)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:GUBERMAN
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 1:2 4TH RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-1506
Mailing Address - Country:US
Mailing Address - Phone:561-466-7871
Mailing Address - Fax:
Practice Address - Street 1:1851 BRUCKNER BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10472-6502
Practice Address - Country:US
Practice Address - Phone:718-892-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025199183500000X
CA23523183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY025199OtherLICENSE
CA23523OtherLICENSE