Healthcare Provider Details

I. General information

NPI: 1902141344
Provider Name (Legal Business Name): MARY JANE JONES RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 WEST ADAMS ST.
BLACK RIVER FALLS WI
54615
US

IV. Provider business mailing address

P.O. BOX 156 610 W. ADAMS ST
BLACK RIVER FALLS WI
54615
US

V. Phone/Fax

Practice location:
  • Phone: 715-284-4089
  • Fax: 715-284-1606
Mailing address:
  • Phone: 715-284-4089
  • Fax: 715-284-1606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8350
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: