Provider Demographics
NPI:1063737575
Name:YESELSON, INNA (PHARMACIST)
Entity type:Individual
Prefix:MRS
First Name:INNA
Middle Name:
Last Name:YESELSON
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1481 ARDEN AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-5407
Mailing Address - Country:US
Mailing Address - Phone:718-966-4405
Mailing Address - Fax:
Practice Address - Street 1:901 WEST MAIN STREET
Practice Address - Street 2:SUITE 162
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728
Practice Address - Country:US
Practice Address - Phone:732-414-1977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS00698600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist