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General NPI Number Information
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NPI Number | 1669877015
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Entity Type | Individual
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Provider Name | JADE ENEVOLDSEN PHARM. D.
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Gender | Male
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Dates
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Enumeration Date | 10/28/2014
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Last Update Date | 10/28/2014
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Provider Practice Location Address
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Address Line | 4308 E GRAND AVE
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City | LARAMIE
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State | WY
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Zip | 82070-5508
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Country | US
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Telephone | 307-745-6112
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Fax | 307-721-4975
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Provider Business Mailing Address
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Address Line | 4308 E GRAND AVE
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City | LARAMIE
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State | WY
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Zip | 82070-5508
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Country | US
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Telephone | 307-745-6112
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Fax | 307-721-4975
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 3784
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License Number State | WY
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