Healthcare Provider Details

I. General information

NPI: 1306128277
Provider Name (Legal Business Name): JENNIFER KAY PUTT PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6201 STELLHORN RD
FORT WAYNE IN
46815-5349
US

IV. Provider business mailing address

6201 STELLHORN RD
FORT WAYNE INDIANA
46815
UM

V. Phone/Fax

Practice location:
  • Phone: 260-485-0755
  • Fax: 260-486-7531
Mailing address:
  • Phone: 260-485-0755
  • Fax: 260-486-7531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26022018A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1849
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: