MEDICARE: JERRY JOSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	066113	NY

General Provider Information

NPI Number	:	1316564818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY JOSE

Provider Business Mailing Address
First Line	:	1616 HIGHLAND AVE
Second Line	:
City	:	NEW HYDE PARK
State	:	NY
Zip	:	11040-3944
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2992 FULTON ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11208-1124
Country	:	US
Telephone Number	:	718-827-8943
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2020
Last Update Date	:	06/30/2020

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Directions to “ JERRY JOSE ” Practice Location

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