Provider Demographics
NPI:1669503306
Name:DEGENHART, JASON JOSEPH (PHARM D RPH)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:JOSEPH
Last Name:DEGENHART
Suffix:
Gender:M
Credentials:PHARM D RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2939 WILD HORSE ST
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-9656
Mailing Address - Country:US
Mailing Address - Phone:309-451-1722
Mailing Address - Fax:
Practice Address - Street 1:2939 WILD HORSE ST
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-9656
Practice Address - Country:US
Practice Address - Phone:309-451-1722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X, 1835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered183500000XPharmacy Service ProvidersPharmacist
Not Answered1835G0303XPharmacy Service ProvidersPharmacistGeriatric