Healthcare Provider Details

I. General information

NPI: 1124313739
Provider Name (Legal Business Name): JENNIFER ANN PUCKETT PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2011
Last Update Date: 06/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 NW GILMAN BLVD T-0996
ISSAQUAH WA
98027-5357
US

IV. Provider business mailing address

755 NW GILMAN BLVD T-0996
ISSAQUAH WA
98027-5357
US

V. Phone/Fax

Practice location:
  • Phone: 425-507-1020
  • Fax: 425-507-1020
Mailing address:
  • Phone: 425-507-1020
  • Fax: 425-507-1020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH60093679
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: