Provider Demographics
NPI:1578816757
Name:JENNE, CHRISTY L (PHARMD)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:L
Last Name:JENNE
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 1:260 W HONEYSUCKLE AVE
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-9270
Mailing Address - Country:US
Mailing Address - Phone:208-762-0185
Mailing Address - Fax:
Practice Address - Street 1:260 W HONEYSUCKLE AVE
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-9270
Practice Address - Country:US
Practice Address - Phone:208-762-0185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6736183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist