Provider Demographics
NPI:1235370404
Name:WASSON, WENDY ANN (CPHT)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:ANN
Last Name:WASSON
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12590 BLUE LAGOON TRL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-5223
Mailing Address - Country:US
Mailing Address - Phone:904-982-9740
Mailing Address - Fax:
Practice Address - Street 1:2104 MASSEY AVE
Practice Address - Street 2:NAVAL STATION MAYPORT
Practice Address - City:MAYPORT
Practice Address - State:FL
Practice Address - Zip Code:32227
Practice Address - Country:US
Practice Address - Phone:904-270-4205
Practice Address - Fax:904-270-4454
Is Sole Proprietor?:No
Enumeration Date:2009-03-17
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL140103449279957183700000X, 247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
140103449279957OtherCERTIFIED PHARMACY TECHNICIAN