Provider Demographics
NPI:1417175464
Name:SPENCER, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:SPENCER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JASON
Other - Middle Name:
Other - Last Name:SPENCER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:EVA
Mailing Address - State:AL
Mailing Address - Zip Code:35621-0098
Mailing Address - Country:US
Mailing Address - Phone:256-796-7131
Mailing Address - Fax:256-796-0316
Practice Address - Street 1:4109 EVA RD
Practice Address - Street 2:
Practice Address - City:EVA
Practice Address - State:AL
Practice Address - Zip Code:35621-7648
Practice Address - Country:US
Practice Address - Phone:256-796-7131
Practice Address - Fax:256-796-0316
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15253183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist