Provider Demographics
NPI:1164898193
Name:NORTHERN, JEREMIAH ROSENDO (PHARM D)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:ROSENDO
Last Name:NORTHERN
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 BOSQUE BLVD
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-4442
Mailing Address - Country:US
Mailing Address - Phone:254-399-0067
Mailing Address - Fax:
Practice Address - Street 1:5401 BOSQUE BLVD
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-4442
Practice Address - Country:US
Practice Address - Phone:254-399-0067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX56799183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist