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NPI Code Detail

MEDICARE: MS. JACQUESE LYNEL WOODRUFF PHARMD

MEDICARE: MS. JACQUESE LYNEL WOODRUFF PHARMD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1390200000XStudent in an Organized Health Care Education/Training Program45022964AIN

General Provider Information

NPI Number : 1770251530
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. JACQUESE LYNEL WOODRUFF PHARMD
Provider Business Mailing Address
First Line : 11013 CALERA PSGE
Second Line :
City : ROANOKE
State : IN
Zip : 46783-8606
Country : US
Telephone Number : 260-200-8714
Fax Number :
Provider Business Practice Location Address
First Line : 10627 DIEBOLD RD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46845-8606
Country : US
Telephone Number : 260-470-2700
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/04/2021
Last Update Date : 09/04/2021

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