Provider Demographics
NPI:1285161505
Name:LIU, JONATHAN
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:LIU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 WOODCHUCK LN
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897-3427
Mailing Address - Country:US
Mailing Address - Phone:646-789-2558
Mailing Address - Fax:
Practice Address - Street 1:75 MAIN ST
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-7802
Practice Address - Country:US
Practice Address - Phone:203-791-0405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0013799183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist