MEDICARE: MARK JAKUBOWSKI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	051153	NY

General Provider Information

NPI Number	:	1447654728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK JAKUBOWSKI

Provider Business Mailing Address
First Line	:	73 PORT AVE
Second Line	:
City	:	RONKONKOMA
State	:	NY
Zip	:	11779-5929
Country	:	US
Telephone Number	:	631-647-0113
Fax Number	:

Provider Business Practice Location Address
First Line	:	73 PORT AVE
Second Line	:
City	:	RONKONKOMA
State	:	NY
Zip	:	11779-5929
Country	:	US
Telephone Number	:	631-647-0113
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/15/2014
Last Update Date	:	10/15/2014

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