Provider Demographics
NPI:1275142457
Name:MASSEY, JEREMY RAPHAEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:RAPHAEL
Last Name:MASSEY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6586 N BETHMAUR LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-3320
Mailing Address - Country:US
Mailing Address - Phone:847-208-2191
Mailing Address - Fax:
Practice Address - Street 1:2727 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-1549
Practice Address - Country:US
Practice Address - Phone:414-933-9350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20267-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist