=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417632159
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORGE ARTURO JIMENEZ MORALES PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2023
-----------------------------------------------------
Last Update Date | 06/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2061 WESTERN AVE
-----------------------------------------------------
City | GUILDERLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12084-9559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-869-1520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2061 WESTERN AVE
-----------------------------------------------------
City | GUILDERLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12084-9559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-869-1520
-----------------------------------------------------
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 | 070373
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------