Healthcare Provider Details

I. General information

NPI: 1508692443
Provider Name (Legal Business Name): JESSICA BUETTNER RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 S 11TH ST
NILES MI
49120-3402
US

IV. Provider business mailing address

451 W THOMPSON RD
INDIANAPOLIS IN
46217-3529
US

V. Phone/Fax

Practice location:
  • Phone: 269-683-0234
  • Fax:
Mailing address:
  • Phone: 306-960-4455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302415979
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: