Healthcare Provider Details

I. General information

NPI: 1427664713
Provider Name (Legal Business Name): JASMINE GEORGE AE-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 09/22/2020
Certification Date: 09/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 GRAND CONCOURSE MAIN BASEMENT PHARMACY
BRONX NY
10457
US

IV. Provider business mailing address

1650 GRAND AVE BSMT PHARMACY
BRONX NY
10453-7886
US

V. Phone/Fax

Practice location:
  • Phone: 718-518-5020
  • Fax: 718-518-5298
Mailing address:
  • Phone: 718-518-5020
  • Fax: 718-518-5298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number057460
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number057460
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: