Healthcare Provider Details

I. General information

NPI: 1114388493
Provider Name (Legal Business Name): JERRY SKOLNICK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 N 12TH ST SUIUTE 110
PHILADELPHIA PA
19107-1102
US

IV. Provider business mailing address

340 N 12TH ST SUIUTE 110
PHILADELPHIA PA
19107-1102
US

V. Phone/Fax

Practice location:
  • Phone: 844-274-4103
  • Fax: 267-758-6330
Mailing address:
  • Phone: 844-274-4103
  • Fax: 267-758-6330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP028193L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RIO1465000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: