Healthcare Provider Details

I. General information

NPI: 1124882592
Provider Name (Legal Business Name): JENNIFER LYNN BOOTH PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2024
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 MAIN ST STE A
SWEET HOME OR
97386-3339
US

IV. Provider business mailing address

621 MAIN ST STE A
SWEET HOME OR
97386-3339
US

V. Phone/Fax

Practice location:
  • Phone: 541-367-6777
  • Fax: 541-367-6500
Mailing address:
  • Phone: 541-367-6777
  • Fax: 541-367-6500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0019227
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: