Basic Information
| Provider Information | |||||||||
| NPI: | 1033557913 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DETTRA | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | PHARM.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5916 SAPPHIRE CT | ||||||||
| Address2: | |||||||||
| City: | GROVE CITY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431238361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405060112 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5916 SAPPHIRE CT | ||||||||
| Address2: | |||||||||
| City: | GROVE CITY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431238361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405060112 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2013 | ||||||||
| LastUpdateDate: | 11/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P2201X | RP0008981 | WV | N | 183500000X | 03129750 | OH | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.