Provider Demographics
NPI:1376890558
Name:FORD, JACQUELINE MARIE (RPH)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:FORD
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 1:3231 S. NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7304
Mailing Address - Country:US
Mailing Address - Phone:417-841-0116
Mailing Address - Fax:417-888-5609
Practice Address - Street 1:3231 S. NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7304
Practice Address - Country:US
Practice Address - Phone:417-841-0116
Practice Address - Fax:417-888-5609
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO29328183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist