Provider Demographics
NPI:1043810153
Name:DECOURSEY, JENNIFER RAE (RPH)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAE
Last Name:DECOURSEY
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 1:6730 N CAMP ARTHUR RD
Mailing Address - Street 2:
Mailing Address - City:BRUCEVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47516-6244
Mailing Address - Country:US
Mailing Address - Phone:812-890-6557
Mailing Address - Fax:
Practice Address - Street 1:757 W WOLFE ST
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-7116
Practice Address - Country:US
Practice Address - Phone:812-268-4626
Practice Address - Fax:812-268-4731
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019557A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist