=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801417704
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAY N SURATI PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2020
-----------------------------------------------------
Last Update Date | 05/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2084 OTAY LAKES RD STE 102
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91913-1368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-289-9606
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 221 DONAX AVE UNIT 12
-----------------------------------------------------
City | IMPERIAL BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91932-1938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-322-6254
-----------------------------------------------------
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 | 70317
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------