Healthcare Provider Details

I. General information

NPI: 1942202379
Provider Name (Legal Business Name): JENNIFER MARIE GEORGE PHARM.D,
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6408 COPPS AVENUE
MONONA WI
53716
US

IV. Provider business mailing address

202 SOUTH PARK STREET
MADISON WI
53715
US

V. Phone/Fax

Practice location:
  • Phone: 608-417-7115
  • Fax: 608-417-3001
Mailing address:
  • Phone: 608-417-7115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14143-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: