Provider Demographics
NPI:1619378478
Name:JENNINGS, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:JENNINGS
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 1:3027 WADE HAMPTON BLVD
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687
Mailing Address - Country:US
Mailing Address - Phone:864-292-2014
Mailing Address - Fax:864-292-8992
Practice Address - Street 1:3027 WADE HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:TAYLORS
Practice Address - State:SC
Practice Address - Zip Code:29687
Practice Address - Country:US
Practice Address - Phone:864-292-2014
Practice Address - Fax:864-292-8992
Is Sole Proprietor?:No
Enumeration Date:2014-09-11
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35796183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist