Healthcare Provider Details

I. General information

NPI: 1134188345
Provider Name (Legal Business Name): ROBERT JACOBSON PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 S LAKE BLVD SUITE 7
MAHOPAC NY
10541-3218
US

IV. Provider business mailing address

935 S LAKE BLVD SUITE 7
MAHOPAC NY
10541-3218
US

V. Phone/Fax

Practice location:
  • Phone: 845-621-2571
  • Fax: 845-621-2572
Mailing address:
  • Phone: 845-621-2571
  • Fax: 845-621-2572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number027348
License Number StateNY

VIII. Authorized Official

Name: MR. GARY CYRAN
Title or Position: VICE PRESIDENT
Credential: RPH
Phone: 845-621-2571