Provider Demographics
NPI:1679166300
Name:MCINTYRE, JENNIFER DENISE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DENISE
Last Name:MCINTYRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:DENISE
Other - Last Name:BUNCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CPHT
Mailing Address - Street 1:1006 CAROLINE ST
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:42262-9153
Mailing Address - Country:US
Mailing Address - Phone:740-605-8750
Mailing Address - Fax:
Practice Address - Street 1:14800 FORT CAMPBELL BLVD
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:KY
Practice Address - Zip Code:42262-8304
Practice Address - Country:US
Practice Address - Phone:270-640-5848
Practice Address - Fax:270-640-5844
Is Sole Proprietor?:No
Enumeration Date:2021-02-13
Last Update Date:2021-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30114462183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30114462OtherCPHT