Provider Demographics
NPI:1497004915
Name:AVESON, JENNIFER T (RPH)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:T
Last Name:AVESON
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 1:1512 HOLLY DR
Mailing Address - Street 2:UNIT 104
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-4089
Mailing Address - Country:US
Mailing Address - Phone:804-400-3843
Mailing Address - Fax:
Practice Address - Street 1:601 HIGHWAY 17 N
Practice Address - Street 2:
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-6024
Practice Address - Country:US
Practice Address - Phone:843-238-5628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13536183500000X
VA0202012200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist