Provider Demographics
NPI:1982063707
Name:LI, JACKEY KIN-MING (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACKEY
Middle Name:KIN-MING
Last Name:LI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 VYSE AVE
Mailing Address - Street 2:APT. 4C
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10460-4351
Mailing Address - Country:US
Mailing Address - Phone:347-450-7490
Mailing Address - Fax:
Practice Address - Street 1:961 E 174TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10460-5060
Practice Address - Country:US
Practice Address - Phone:718-860-3363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061403183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist