Provider Demographics
NPI:1588253108
Name:TANSKI, JEROME L
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:L
Last Name:TANSKI
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 1:642 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:TIERRA VERDE
Mailing Address - State:FL
Mailing Address - Zip Code:33715-2001
Mailing Address - Country:US
Mailing Address - Phone:727-692-3987
Mailing Address - Fax:
Practice Address - Street 1:642 6TH AVE N
Practice Address - Street 2:
Practice Address - City:TIERRA VERDE
Practice Address - State:FL
Practice Address - Zip Code:33715-2001
Practice Address - Country:US
Practice Address - Phone:727-692-3987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS48746183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist