Provider Demographics
NPI:1063289833
Name:COSTELLO, JENNIFER LYNN (RPH)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LYNN
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 BLUEBERRY HOLLOW CT
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-4924
Mailing Address - Country:US
Mailing Address - Phone:407-493-8047
Mailing Address - Fax:
Practice Address - Street 1:600 E ALTAMONTE DR STE 1400
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-4829
Practice Address - Country:US
Practice Address - Phone:321-972-3955
Practice Address - Fax:321-972-3963
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS28607183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist