Healthcare Provider Details

I. General information

NPI: 1013562057
Provider Name (Legal Business Name): JENNIFER GOZUM RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 10/25/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 ROUTE 8 CHALAN MACHAUTE
MAITE GU
96910
US

IV. Provider business mailing address

751 ROUTE 8 CHALAN MACHAUTE
MAITE GU
96910
US

V. Phone/Fax

Practice location:
  • Phone: 671-477-3627
  • Fax: 671-477-5589
Mailing address:
  • Phone: 671-477-3627
  • Fax: 671-477-5589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH0331
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: