Provider Demographics
NPI:1992415459
Name:DIAZ, JASON (PHARMD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:DIAZ
Suffix:
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 1:396 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-2238
Mailing Address - Country:US
Mailing Address - Phone:516-974-7576
Mailing Address - Fax:
Practice Address - Street 1:201 GLEN ST
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2734
Practice Address - Country:US
Practice Address - Phone:516-671-1520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-24
Last Update Date:2022-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069895183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist