Provider Demographics
NPI:1417220666
Name:SMITH, JASON WAYNE (RPH)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:WAYNE
Last Name:SMITH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 RIVER CHASE DR
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867-7483
Mailing Address - Country:US
Mailing Address - Phone:334-732-3532
Mailing Address - Fax:334-732-3535
Practice Address - Street 1:4401 RIVER CHASE DR
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-7483
Practice Address - Country:US
Practice Address - Phone:334-732-3532
Practice Address - Fax:334-732-3535
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12724183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist