Provider Demographics
NPI:1679857478
Name:LAFOLLETTE, JEREMY (PHARMD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:LAFOLLETTE
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 1:2008 N WOODBINE RD
Mailing Address - Street 2:APT 5
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2439
Mailing Address - Country:US
Mailing Address - Phone:816-617-4929
Mailing Address - Fax:
Practice Address - Street 1:1191 W KANSAS ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-2281
Practice Address - Country:US
Practice Address - Phone:816-781-9347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007019775183500000X
KS1-14728183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist