Provider Demographics
NPI:1215290184
Name:NEVENS, JEFFREY RICHARD (RPH)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RICHARD
Last Name:NEVENS
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 1:1200 W FOND DU LAC ST
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:WI
Mailing Address - Zip Code:54971-9288
Mailing Address - Country:US
Mailing Address - Phone:920-748-1203
Mailing Address - Fax:920-748-4803
Practice Address - Street 1:1200 W FOND DU LAC ST
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:WI
Practice Address - Zip Code:54971-9288
Practice Address - Country:US
Practice Address - Phone:920-748-1203
Practice Address - Fax:920-748-4803
Is Sole Proprietor?:No
Enumeration Date:2012-06-16
Last Update Date:2012-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12634183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist