1669920385 NPI number — JENNA VAUGHN PHARMD

Table of content: JENNA VAUGHN PHARMD (NPI 1669920385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669920385 NPI number — JENNA VAUGHN PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAUGHN
Provider First Name:
JENNA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669920385
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 E GREENWAY PKWY
Provider Second Line Business Mailing Address:
APT 2007
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85022-2527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-964-5641
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23620 N 20TH DR
Provider Second Line Business Practice Location Address:
SUITE 12
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85085-0621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-546-5779
Provider Business Practice Location Address Fax Number:
877-546-5780
Provider Enumeration Date:
09/12/2016

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:  S022155 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: S022155 . This is a "ARIZONA PHARMACIST LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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