Provider Demographics
NPI:1538559331
Name:JENNEWINE, TREVOR (RPH)
Entity type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:
Last Name:JENNEWINE
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 1:2665 NW GARRYANNA DR
Mailing Address - Street 2:2
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3686
Mailing Address - Country:US
Mailing Address - Phone:937-654-5025
Mailing Address - Fax:
Practice Address - Street 1:1990 14TH AVE SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-8504
Practice Address - Country:US
Practice Address - Phone:541-812-2386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-31
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0014533183500000X
OR00145331835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORRPH-0014533OtherOREGON BOARD OF PHARMACY