Provider Demographics
NPI:1881386035
Name:JOHN, JENNIE (RPH)
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:JOHN
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 1:166 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:VALHALLA
Mailing Address - State:NY
Mailing Address - Zip Code:10595-1833
Mailing Address - Country:US
Mailing Address - Phone:914-417-1246
Mailing Address - Fax:
Practice Address - Street 1:500 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:WEST HARRISON
Practice Address - State:NY
Practice Address - Zip Code:10604-3200
Practice Address - Country:US
Practice Address - Phone:914-367-7015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0612961835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology