Provider Demographics
NPI:1619359064
Name:MYERS, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:MYERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 N NELSON DR
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-2572
Mailing Address - Country:US
Mailing Address - Phone:316-788-3737
Mailing Address - Fax:
Practice Address - Street 1:2020 N NELSON DR
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-2572
Practice Address - Country:US
Practice Address - Phone:316-788-3737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-16727183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist