Provider Demographics
NPI:1003219031
Name:LARE, JODI ELAINE (BACHELOR OF PHARMACY)
Entity Type:Individual
Prefix:MRS
First Name:JODI
Middle Name:ELAINE
Last Name:LARE
Suffix:
Gender:F
Credentials:BACHELOR OF PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2022 WILTONWOOD RD
Mailing Address - Street 2:
Mailing Address - City:STEVENSON
Mailing Address - State:MD
Mailing Address - Zip Code:21153-0681
Mailing Address - Country:US
Mailing Address - Phone:410-493-6228
Mailing Address - Fax:
Practice Address - Street 1:4370 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-6006
Practice Address - Country:US
Practice Address - Phone:410-203-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-05
Last Update Date:2014-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13111183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist