=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003064098
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY GARY LUCKS RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2008
-----------------------------------------------------
Last Update Date | 09/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 602 BRIGHTON BEACH AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11235-6456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-332-3708
-----------------------------------------------------
Fax | 718-332-5737
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 602 BRIGHTON BEACH AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11235-6456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-332-3708
-----------------------------------------------------
Fax | 718-332-5737
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 028282
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------