Provider Demographics
NPI:1194100495
Name:BRYAN, JEANNE KATELYN (PHARMD)
Entity type:Individual
Prefix:
First Name:JEANNE
Middle Name:KATELYN
Last Name:BRYAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8502
Mailing Address - Country:US
Mailing Address - Phone:631-665-8470
Mailing Address - Fax:
Practice Address - Street 1:480 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8502
Practice Address - Country:US
Practice Address - Phone:631-665-8470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-28
Last Update Date:2016-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060723183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist