=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881800381
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH KOCHADATHIL JIBI
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2007
-----------------------------------------------------
Last Update Date | 12/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8445 FRANKFORD AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-333-0535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4427 MASTER AVE
-----------------------------------------------------
City | TREVOSE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19053-6926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-335-2760
-----------------------------------------------------
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 | RP441571
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------