Healthcare Provider Details

I. General information

NPI: 1801564414
Provider Name (Legal Business Name): JAY PANCHAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 MAPLE AVENUE
NETCONG NJ
07857-1125
US

IV. Provider business mailing address

17 MAPLE AVE
NETCONG NJ
07857-1125
US

V. Phone/Fax

Practice location:
  • Phone: 973-347-0068
  • Fax:
Mailing address:
  • Phone: 973-347-0068
  • Fax: 973-347-6765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI03728100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: