Provider Demographics
NPI:1982243788
Name:1105 JTP LLC
Entity Type:Organization
Organization Name:1105 JTP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ISHBAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUKUROV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-775-7775
Mailing Address - Street 1:1105 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-4603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1105 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-4603
Practice Address - Country:US
Practice Address - Phone:516-775-7775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-27
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy