Provider Demographics
NPI:1003287863
Name:REGALIA, JENNIFER ROSE (RPH)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:REGALIA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6725 OTTER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:FALL CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:54742-9378
Mailing Address - Country:US
Mailing Address - Phone:715-529-0868
Mailing Address - Fax:715-832-3766
Practice Address - Street 1:3184 LONDON RD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6834
Practice Address - Country:US
Practice Address - Phone:715-529-0868
Practice Address - Fax:715-832-3766
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI109721835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10972OtherSTATE LISCENSING BOARD