Provider Demographics
NPI:1932430576
Name:TEDESCO, JENNIFER (RPH)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:TEDESCO
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 1:2650 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-1000
Mailing Address - Country:US
Mailing Address - Phone:631-859-5120
Mailing Address - Fax:631-859-5182
Practice Address - Street 1:2650 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-1000
Practice Address - Country:US
Practice Address - Phone:631-859-5120
Practice Address - Fax:631-859-5182
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048430-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist