Provider Demographics
NPI:1972103356
Name:SMITH, JASON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:SMITH
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 1:320 136TH ST UNIT E
Mailing Address - Street 2:
Mailing Address - City:OCEAN CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21842-4562
Mailing Address - Country:US
Mailing Address - Phone:443-783-5948
Mailing Address - Fax:
Practice Address - Street 1:11416 OCEAN GTWY
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-2549
Practice Address - Country:US
Practice Address - Phone:410-629-1842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25921183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist