Provider Demographics
NPI:1447031661
Name:KANN, JACK (RPH)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:KANN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 WOODY LN
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-3251
Mailing Address - Country:US
Mailing Address - Phone:631-903-7092
Mailing Address - Fax:
Practice Address - Street 1:15 WOODY LN
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-3251
Practice Address - Country:US
Practice Address - Phone:631-903-7092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY36921183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist