Provider Demographics
NPI:1306187497
Name:JIMMICUM, VICTORIA ANN
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:ANN
Last Name:JIMMICUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 273
Mailing Address - Street 2:
Mailing Address - City:NEAH BAY
Mailing Address - State:WA
Mailing Address - Zip Code:98357-0273
Mailing Address - Country:US
Mailing Address - Phone:360-640-4200
Mailing Address - Fax:
Practice Address - Street 1:250 FORT STREET
Practice Address - Street 2:
Practice Address - City:NEAH BAY
Practice Address - State:WA
Practice Address - Zip Code:98357
Practice Address - Country:US
Practice Address - Phone:360-645-2445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA60214288183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician