Provider Demographics
NPI:1154151884
Name:HENDERSON, JONATHAN (PHARMD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11232 BUGENHAGEN DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832-7032
Mailing Address - Country:US
Mailing Address - Phone:407-488-2820
Mailing Address - Fax:
Practice Address - Street 1:3500 GASTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2088
Practice Address - Country:US
Practice Address - Phone:407-488-2820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74203183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist