Provider Demographics
NPI:1104398775
Name:WILLIAMS, JAQUAN M (PHARMD)
Entity Type:Individual
Prefix:
First Name:JAQUAN
Middle Name:M
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:292 BRANCH BROOK DR APT A
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-3624
Mailing Address - Country:US
Mailing Address - Phone:315-374-1630
Mailing Address - Fax:
Practice Address - Street 1:265 PASCACK RD
Practice Address - Street 2:
Practice Address - City:TOWNSHIP OF WASHINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07676-4809
Practice Address - Country:US
Practice Address - Phone:201-664-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03996400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist