Provider Demographics
NPI:1194306001
Name:TOMICHEN, JESLIN ANNA
Entity type:Individual
Prefix:
First Name:JESLIN
Middle Name:ANNA
Last Name:TOMICHEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-4915
Mailing Address - Country:US
Mailing Address - Phone:516-996-6166
Mailing Address - Fax:
Practice Address - Street 1:417 N BROADWAY
Practice Address - Street 2:
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-2106
Practice Address - Country:US
Practice Address - Phone:516-938-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065685183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist