1396819777 NPI number — MRS. COLLEEN LEARY JOCHEM RPH PHARM D

Table of content: MS. LAURA JANE LUTTON POLLARD LMFT (NPI 1831425057)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396819777 NPI number — MRS. COLLEEN LEARY JOCHEM RPH PHARM D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOCHEM
Provider First Name:
COLLEEN
Provider Middle Name:
LEARY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RPH PHARM D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEARY
Provider Other First Name:
COLLEEN
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RPH PHARM D
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1396819777
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
993 NE ORANGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JENSEN BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34957
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-334-2777
Provider Business Mailing Address Fax Number:
772-334-8444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2160 SOUTH FEDERAL HIGHWAY
Provider Second Line Business Practice Location Address:
WINN DIXIE PHARMACY STORE 307
Provider Business Practice Location Address City Name:
STUART
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34994
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-221-3402
Provider Business Practice Location Address Fax Number:
772-221-3505
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  PS23178 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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