Healthcare Provider Details

I. General information

NPI: 1558340711
Provider Name (Legal Business Name): JAY MANDRA PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2006
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20685 CORKSCREW SHORES BLVD
ESTERO FL
33928-9167
US

IV. Provider business mailing address

20685 CORKSCREW SHORES BLVD
ESTERO FL
33928-9167
US

V. Phone/Fax

Practice location:
  • Phone: 815-955-3688
  • Fax:
Mailing address:
  • Phone: 815-955-3688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License NumberPS63633
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051-287659
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: