Provider Demographics
NPI:1336773142
Name:WANG, JENNIFER (PHARMD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 E KOLONELS WAY
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-9089
Mailing Address - Country:US
Mailing Address - Phone:360-452-3105
Mailing Address - Fax:
Practice Address - Street 1:3411 E KOLONELS WAY
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-9089
Practice Address - Country:US
Practice Address - Phone:360-452-3105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60965372183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty