Provider Demographics
NPI:1316554330
Name:THEISS, JACY CHRISTENA (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACY
Middle Name:CHRISTENA
Last Name:THEISS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4649 WINTERSET DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-8112
Mailing Address - Country:US
Mailing Address - Phone:330-435-5037
Mailing Address - Fax:
Practice Address - Street 1:859 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-3940
Practice Address - Country:US
Practice Address - Phone:740-654-2592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03439647183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03439647OtherOHIO PHARMACIST LICENSE NUMBER