Provider Demographics
NPI:1326685108
Name:GRUEL-FIELDS, JEYDA DELREESE (RPH)
Entity Type:Individual
Prefix:
First Name:JEYDA
Middle Name:DELREESE
Last Name:GRUEL-FIELDS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5426 TOMAHAWK TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4938
Mailing Address - Country:US
Mailing Address - Phone:260-602-4371
Mailing Address - Fax:
Practice Address - Street 1:7008 BLUFFTON RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46809-2706
Practice Address - Country:US
Practice Address - Phone:260-747-4136
Practice Address - Fax:260-747-4137
Is Sole Proprietor?:No
Enumeration Date:2019-11-29
Last Update Date:2019-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26020088A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist