Provider Demographics
NPI:1568062354
Name:RHOTENBERRY, JESSICA (RPH)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:RHOTENBERRY
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 1:3600 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-6113
Mailing Address - Country:US
Mailing Address - Phone:918-252-9297
Mailing Address - Fax:918-252-9307
Practice Address - Street 1:3600 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-6113
Practice Address - Country:US
Practice Address - Phone:918-252-9297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18944183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist