Provider Demographics
NPI:1548488075
Name:CORSO, JASPER (RPH)
Entity type:Individual
Prefix:
First Name:JASPER
Middle Name:
Last Name:CORSO
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 1:20 COCONUT DR
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-1222
Mailing Address - Country:US
Mailing Address - Phone:631-368-0801
Mailing Address - Fax:631-927-2007
Practice Address - Street 1:625 BROADHOLLOW RD
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-5006
Practice Address - Country:US
Practice Address - Phone:631-293-8154
Practice Address - Fax:631-927-2007
Is Sole Proprietor?:No
Enumeration Date:2007-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028892183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY028892OtherPHARMACY LICENSE