Provider Demographics
NPI:1962801100
Name:WEBSTER, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:WEBSTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 S ALLISON AVE
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-3622
Mailing Address - Country:US
Mailing Address - Phone:937-372-1677
Mailing Address - Fax:
Practice Address - Street 1:34 S ALLISON AVE
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-3622
Practice Address - Country:US
Practice Address - Phone:937-372-1677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03233755183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist