Healthcare Provider Details

I. General information

NPI: 1386620425
Provider Name (Legal Business Name): JENET ENG LAY AW PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 11/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CORNER OF ROUTE 12 AND 7
FORT DEFIANCE AZ
86504-0649
US

IV. Provider business mailing address

PO BOX 649 HWY 12 NR110
FORT DEFIANCE AZ
86504-0649
US

V. Phone/Fax

Practice location:
  • Phone: 928-729-8328
  • Fax:
Mailing address:
  • Phone: 928-729-8328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH60218349
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: