Provider Demographics
NPI:1154853166
Name:KO, JANNIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JANNIE
Middle Name:
Last Name:KO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-2542
Mailing Address - Country:US
Mailing Address - Phone:860-346-7628
Mailing Address - Fax:
Practice Address - Street 1:633 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-2542
Practice Address - Country:US
Practice Address - Phone:860-346-7628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH237040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist