Provider Demographics
NPI:1689983942
Name:CARROLL, JENNIFER D (RPH)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:D
Last Name:CARROLL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 ROBISON CT
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-6890
Mailing Address - Country:US
Mailing Address - Phone:636-332-9976
Mailing Address - Fax:636-528-6905
Practice Address - Street 1:10 CENTERLINE DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1393
Practice Address - Country:US
Practice Address - Phone:636-462-7005
Practice Address - Fax:636-528-6905
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002027545183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist