Provider Demographics
NPI:1528056108
Name:ILTZ, JASON LOUIS (BPHARM, PHARMD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:LOUIS
Last Name:ILTZ
Suffix:
Gender:M
Credentials:BPHARM, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 404
Mailing Address - Street 2:
Mailing Address - City:VALLEYFORD
Mailing Address - State:WA
Mailing Address - Zip Code:99036-0404
Mailing Address - Country:US
Mailing Address - Phone:509-979-1926
Mailing Address - Fax:
Practice Address - Street 1:12404 S. CARTER RD
Practice Address - Street 2:
Practice Address - City:VALLEYFORD
Practice Address - State:WA
Practice Address - Zip Code:99036
Practice Address - Country:US
Practice Address - Phone:509-979-1926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-08
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH000194041835N1003X, 1835P0018X, 1835P1200X, 261QI0500X, 261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No1835N1003XPharmacy Service ProvidersPharmacistNutrition Support
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain