Provider Demographics
NPI:1982974192
Name:GOLSTON, JERMEL E
Entity Type:Individual
Prefix:MR
First Name:JERMEL
Middle Name:E
Last Name:GOLSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3675 VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46409-1354
Mailing Address - Country:US
Mailing Address - Phone:219-742-0064
Mailing Address - Fax:
Practice Address - Street 1:6510 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-2748
Practice Address - Country:US
Practice Address - Phone:219-931-3332
Practice Address - Fax:219-852-9201
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26023408A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist