=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073148524
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACKLEEN HASABALLA R.PH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2020
-----------------------------------------------------
Last Update Date | 03/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7521 MYRTLE AVE
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11385-7419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-366-2109
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8422 13TH AVE APT 2F
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11228-3339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-535-2847
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 065496-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------