Provider Demographics
NPI:1598050445
Name:WAGEMAN, JESSE SUE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:SUE
Last Name:WAGEMAN
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 1:1201 EAST GILBERT AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-2333
Mailing Address - Country:US
Mailing Address - Phone:208-916-6879
Mailing Address - Fax:
Practice Address - Street 1:4845 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2333
Practice Address - Country:US
Practice Address - Phone:208-237-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-17
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDE3950183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist