=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578514766
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JILLSCOTT CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2006
-----------------------------------------------------
Last Update Date | 09/13/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 54 DEER SHORE SQ
-----------------------------------------------------
City | NORTH BABYLON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11703-1207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-667-2484
-----------------------------------------------------
Fax | 631-667-8887
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 54 DEER SHORE SQ
-----------------------------------------------------
City | NORTH BABYLON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11703-1207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | FRANK DELLISANTI
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 631-667-2484
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 15487
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------