Provider Demographics
NPI:1003226804
Name:TATE, JEFFREY (RPH)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:TATE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10713 ALBERTA DR
Mailing Address - Street 2:
Mailing Address - City:FAIRDALE
Mailing Address - State:KY
Mailing Address - Zip Code:40118-9306
Mailing Address - Country:US
Mailing Address - Phone:502-361-7696
Mailing Address - Fax:
Practice Address - Street 1:9905 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40272-3943
Practice Address - Country:US
Practice Address - Phone:502-995-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-01
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY008149183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist