Provider Demographics
NPI:1487369021
Name:LIN, JACKY
Entity type:Individual
Prefix:
First Name:JACKY
Middle Name:
Last Name:LIN
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 1:3859 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1540
Mailing Address - Country:US
Mailing Address - Phone:212-928-7700
Mailing Address - Fax:917-398-1308
Practice Address - Street 1:3859 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1540
Practice Address - Country:US
Practice Address - Phone:212-928-7700
Practice Address - Fax:917-398-1308
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI069570183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist