Provider Demographics
NPI:1093853335
Name:JAQUETH, FREDRICK THOMAS (RPH)
Entity Type:Individual
Prefix:MR
First Name:FREDRICK
Middle Name:THOMAS
Last Name:JAQUETH
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 1:906 MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-2014
Mailing Address - Country:US
Mailing Address - Phone:406-293-3958
Mailing Address - Fax:406-293-5858
Practice Address - Street 1:906 MONTANA AVE
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-2014
Practice Address - Country:US
Practice Address - Phone:406-293-3958
Practice Address - Fax:406-293-5858
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT884183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0220201Medicaid
MT0220201Medicaid