Provider Demographics
NPI:1447654728
Name:JAKUBOWSKI, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JAKUBOWSKI
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 1:73 PORT AVE
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-5929
Mailing Address - Country:US
Mailing Address - Phone:631-647-0113
Mailing Address - Fax:
Practice Address - Street 1:73 PORT AVE
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-5929
Practice Address - Country:US
Practice Address - Phone:631-647-0113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051153183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist