Provider Demographics
NPI:1538715115
Name:JENSEN, ANTHONY KEITH (RPH)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:KEITH
Last Name:JENSEN
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 1:10038 W STATE ROAD 154
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IN
Mailing Address - Zip Code:47882-7149
Mailing Address - Country:US
Mailing Address - Phone:502-500-0177
Mailing Address - Fax:812-847-2146
Practice Address - Street 1:1709 E STATE HIGHWAY 54
Practice Address - Street 2:
Practice Address - City:LINTON
Practice Address - State:IN
Practice Address - Zip Code:47441-9589
Practice Address - Country:US
Practice Address - Phone:812-847-2226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-10
Last Update Date:2019-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26026077A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist