Provider Demographics
NPI:1962620591
Name:BORMANN, JAY HARVEY (RPH)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:HARVEY
Last Name:BORMANN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6316 DRAKES BAY RUN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-9613
Mailing Address - Country:US
Mailing Address - Phone:260-486-2092
Mailing Address - Fax:260-485-3993
Practice Address - Street 1:4522 MAPLECREST RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-3970
Practice Address - Country:US
Practice Address - Phone:260-485-9628
Practice Address - Fax:260-485-3993
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26016180A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist