Basic Information
Provider Information
NPI: 1033557913
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SIMON
FirstName: JENNIFER
MiddleName: L
NamePrefix:  
NameSuffix:  
Credential: PHARM.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2313 WASHINGTON ST E APT 2
Address2:  
City: CHARLESTON
State: WV
PostalCode: 253112322
CountryCode: US
TelephoneNumber: 7405060112
FaxNumber:  
Practice Location
Address1: 2300 MACCORKLE AVE SE
Address2:  
City: CHARLESTON
State: WV
PostalCode: 253041045
CountryCode: US
TelephoneNumber: 3043574850
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/12/2013
LastUpdateDate: 12/17/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000X03129750OHN Pharmacy Service ProvidersPharmacist 
1835P2201XRP0008981WVY    

No ID Information.


Home