Provider Demographics
NPI:1144597345
Name:MIGUEL, JODI MARIE
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:MARIE
Last Name:MIGUEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 SECOND STREET PIKE
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3943
Mailing Address - Country:US
Mailing Address - Phone:215-953-9475
Mailing Address - Fax:215-953-9875
Practice Address - Street 1:690 SECOND STREET PIKE
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-3943
Practice Address - Country:US
Practice Address - Phone:215-953-9475
Practice Address - Fax:215-953-9875
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP046146R183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist