Healthcare Provider Details

I. General information

NPI: 1730638859
Provider Name (Legal Business Name): JARED BRISCOE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2016
Last Update Date: 09/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 W MAIN ST
VERSAILLES OH
45380-1214
US

IV. Provider business mailing address

42 W MAIN ST
VERSAILLES OH
45380-1214
US

V. Phone/Fax

Practice location:
  • Phone: 937-526-3337
  • Fax: 937-526-4118
Mailing address:
  • Phone: 937-526-3337
  • Fax: 937-526-4118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03225312
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: