Healthcare Provider Details

I. General information

NPI: 1063939072
Provider Name (Legal Business Name): JESSICA DIALA PHARMD, RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2017
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24771 JERICHO TPKE
BELLEROSE NY
11426-1533
US

IV. Provider business mailing address

24771 JERICHO TPKE
BELLEROSE NY
11426-1533
US

V. Phone/Fax

Practice location:
  • Phone: 718-749-5923
  • Fax: 718-749-5924
Mailing address:
  • Phone: 718-749-5923
  • Fax: 718-749-5924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number073399
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number25591
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI03852800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: