Provider Demographics
NPI:1215767009
Name:JUBILEE, IVAN THOMAS II (PHARMD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:THOMAS
Last Name:JUBILEE
Suffix:II
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 TOWNE ST APT 204
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-5936
Mailing Address - Country:US
Mailing Address - Phone:607-207-8587
Mailing Address - Fax:
Practice Address - Street 1:537 CANAL ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-5901
Practice Address - Country:US
Practice Address - Phone:203-323-1293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0016766183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist