Provider Demographics
NPI:1487525564
Name:MANDY, JESSIE LYN
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:LYN
Last Name:MANDY
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 1:20422 SW 52ND MNR
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33332-4502
Mailing Address - Country:US
Mailing Address - Phone:954-203-6171
Mailing Address - Fax:
Practice Address - Street 1:4567 WESTON RD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3141
Practice Address - Country:US
Practice Address - Phone:954-217-1195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-13
Last Update Date:2025-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS69506183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty