Provider Demographics
NPI:1164772174
Name:BISCHOFF, JASON LEE
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:LEE
Last Name:BISCHOFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 W COULTER AVENUE
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435
Mailing Address - Country:US
Mailing Address - Phone:307-754-2755
Mailing Address - Fax:
Practice Address - Street 1:1005 W COULTER AVE
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-2530
Practice Address - Country:US
Practice Address - Phone:307-754-2755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3274183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist