Provider Demographics
NPI:1003944323
Name:WOLFENDEN, JEFFRY HERMAN
Entity Type:Individual
Prefix:
First Name:JEFFRY
Middle Name:HERMAN
Last Name:WOLFENDEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JEFFRY
Other - Middle Name:HERMAN
Other - Last Name:WOLFENDEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3913 CLAIRMONT DR NE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-5126
Mailing Address - Country:US
Mailing Address - Phone:423-473-0118
Mailing Address - Fax:
Practice Address - Street 1:2260 CHAMBLISS AVE NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-3843
Practice Address - Country:US
Practice Address - Phone:423-479-8601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7902183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist