Provider Demographics
NPI:1437635729
Name:JETTON, KACY LAYNE (PHARM D)
Entity Type:Individual
Prefix:
First Name:KACY
Middle Name:LAYNE
Last Name:JETTON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15424 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-3029
Mailing Address - Country:US
Mailing Address - Phone:636-256-7922
Mailing Address - Fax:
Practice Address - Street 1:15425 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-3077
Practice Address - Country:US
Practice Address - Phone:636-256-7922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012026452183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist