Provider Demographics
NPI:1972966935
Name:OFFUTT, JEFFERY WAYNE (RPH)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:WAYNE
Last Name:OFFUTT
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 1:1107 E MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5602
Mailing Address - Country:US
Mailing Address - Phone:903-758-2610
Mailing Address - Fax:903-758-7081
Practice Address - Street 1:1107 E MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5602
Practice Address - Country:US
Practice Address - Phone:903-758-2610
Practice Address - Fax:903-758-7081
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35634183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist