Provider Demographics
NPI:1104143494
Name:VARGHESE, JAICY (RPH)
Entity type:Individual
Prefix:
First Name:JAICY
Middle Name:
Last Name:VARGHESE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10610 SAINT THOMAS DR
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-3890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11750 BUSTLETON AVE
Practice Address - Street 2:RITE AID PHARMACY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116
Practice Address - Country:US
Practice Address - Phone:215-934-6221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP439830183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist