Provider Demographics
NPI:1477621894
Name:DIETRICH, JEFFREY JAY (RPH)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:JAY
Last Name:DIETRICH
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 1:550 POPE AVENUE
Mailing Address - Street 2:MUNSON ARMY HEALTH CENTER
Mailing Address - City:FORT LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66027-2332
Mailing Address - Country:US
Mailing Address - Phone:913-684-6562
Mailing Address - Fax:913-684-6208
Practice Address - Street 1:550 POPE AVENUE
Practice Address - Street 2:MUNSON ARMY HEALTH CENTER
Practice Address - City:FORT LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66027-2332
Practice Address - Country:US
Practice Address - Phone:913-684-6562
Practice Address - Fax:913-684-6208
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11655183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist