Provider Demographics
NPI:1609160399
Name:TAYLOR, JEREMY D (PHARMD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:D
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2280 IBSEN AVE
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-1902
Mailing Address - Country:US
Mailing Address - Phone:541-520-6056
Mailing Address - Fax:
Practice Address - Street 1:11913 NE 195TH ST
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3147
Practice Address - Country:US
Practice Address - Phone:425-489-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-31
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA46366183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist