Provider Demographics
NPI:1356862171
Name:WU, JASON WAYNE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:WAYNE
Last Name:WU
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 1:2932 S WALLACE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3035
Mailing Address - Country:US
Mailing Address - Phone:916-715-3661
Mailing Address - Fax:
Practice Address - Street 1:757 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2606
Practice Address - Country:US
Practice Address - Phone:312-664-8686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-01
Last Update Date:2017-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049.220784183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician