Provider Demographics
NPI:1619572617
Name:THEISS, JONATHAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:THEISS
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 1:300 S COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:HARRISONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64701-1648
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 S COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-1648
Practice Address - Country:US
Practice Address - Phone:816-824-6928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017022603183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist