Provider Demographics
NPI:1497036230
Name:GARDNER, JACQUELINE (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 BLUEGRASS PKWY
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-4023
Mailing Address - Country:US
Mailing Address - Phone:630-551-3550
Mailing Address - Fax:
Practice Address - Street 1:100 W VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:YORKVILLE
Practice Address - State:IL
Practice Address - Zip Code:60560-1827
Practice Address - Country:US
Practice Address - Phone:630-553-3759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051292212183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist