=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841393204
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOHAN J JOLLY RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2006
-----------------------------------------------------
Last Update Date | 03/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 95 SCHOOL ST
-----------------------------------------------------
City | GLEN COVE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11542-2511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-676-9111
-----------------------------------------------------
Fax | 516-676-5162
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 BRANDING IRON LN
-----------------------------------------------------
City | GLEN COVE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11542-1638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-676-9111
-----------------------------------------------------
Fax | 516-676-5162
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 030044
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------