Healthcare Provider Details

I. General information

NPI: 1982974192
Provider Name (Legal Business Name): MR. JERMEL E GOLSTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2012
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6510 COLUMBIA AVE
HAMMOND IN
46320-2748
US

IV. Provider business mailing address

3675 VIRGINIA ST
GARY IN
46409-1354
US

V. Phone/Fax

Practice location:
  • Phone: 219-931-3332
  • Fax: 219-852-9201
Mailing address:
  • Phone: 219-742-0064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26023408A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: