MEDICARE: JACKLEEN W. HERMINA

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	13642	MD

General Provider Information

NPI Number	:	1649532847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKLEEN W. HERMINA

Provider Business Mailing Address
First Line	:	4486 ROLLING MDWS
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21043-6573
Country	:	US
Telephone Number	:	410-419-5177
Fax Number	:

Provider Business Practice Location Address
First Line	:	8036 RITCHIE HWY
Second Line	:
City	:	PASADENA
State	:	MD
Zip	:	21122-1084
Country	:	US
Telephone Number	:	410-761-5441
Fax Number	:	410-787-9402

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

Provider Enumeration Date	:	06/13/2012
Last Update Date	:	06/13/2012

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