Healthcare Provider Details

I. General information

NPI: 1962797555
Provider Name (Legal Business Name): JEFFREY HUSTON R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 N MAIN ST
CEDARVILLE OH
45314-8501
US

IV. Provider business mailing address

251 N MAIN ST
CEDARVILLE OH
45314-8501
US

V. Phone/Fax

Practice location:
  • Phone: 937-766-7486
  • Fax:
Mailing address:
  • Phone: 937-766-7486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03318304
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number012310
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: